Asbestos Lung Disease

A Primer for Patients, Physicians and Lawyers

Lawrence Martin, M.D.

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I am a pulmonary physician with experience in diagnosing asbestosis and other asbestos-related lung diseases. Because most cases of alleged asbestos lung disease end up as legal claims, I also have experience working with lawyers involved in asbestos litigation. While the majority of my legal work has been in defense of companies sued by workers, I have also been on the side of patients making asbestos-related claims. This web site has been created without help (financial or otherwise) from any attorneys or attorney advocates, and the views expressed are my own. The addition of Google Ads is to help defray the cost maintaining the site. I have no input into the selection of ads, and of course they have no influence on the content of this web site.

To illustrate both valid and invalid asbestos claims, I have included several cases evaluated over the years. This Primer is written in lay language so as to reach the widest possible audience. Many web links are included and, for some topics, medical references for those who wish to research the topics further.

Unfortunately -- for both true asbestos victims, as well as the legal system and society as a whole -- the process of diagnosing asbestos disease was long ago shanghied by unethical plaintiff attorneys and a small cadre of equally unethical physicians. The result has been what is now known as The United States Asbestos Screening Scam. My separate web site deails the workings of this giant scam. The scam in a nutshell is a decades' long process of filing hundreds of thousands of madeup and/or fraudulent asbestos claims. That these bogus claims -- now no secret to anyone -- continue to clog courts and BWC venues is an indictment of our legal and political system as much as it is of the professionals who manufactured them in the first place.

No doubt the attorneys and physicians who have been part of this giant scam will quit reading by this point. However, the truth is, I am not "pro-industry" and have always felt that workers truly harmed by asbestos deserve their day in court and just compensation. I offer this Asbestos Primer with only one bias -- on the side of consistency, rationality and honesty in diagnosis. (A plea for objectivity in analysis of occupational cases can also be found in my on-line paper Pitfalls in Diagnosis of Occupational Lung Disease For Purposes of Compensation -- One Physician's Perspective.)

Questions Asked and Answered in Primer

What is asbestos?
What are ferruginous bodies?
What is the harm from inhaling asbestos?
Who is at risk for asbestos-related disease?
What are the asbestos-related lung and respiratory diseases?
Are asbestos-related diseases treatable?
What are the symptoms of asbestos-related lung disease?
How does smoking affect asbestos diseases?
What other diseases can occur from asbestos?
How is asbestos lung disease diagnosed?
Why is there so much argument over asbestos?
What are the principal disputes in asbestos-related claims?
What are the specific reasons for most asbestos litigation?
Why is there controvesy over diagnosis of pleural plaques?
Do pleural plaques lead to cancer?
What is the Browne Hypothesis?
What are the standard criteria for diagnosing asbestosis?
What are the Helsinki Criteria?
How are claims based only on the chest x-ray?
What results from claims based only on the chest x-ray?
Is there a solution to the asbestos-litigation problem?
What are the legal impediments to a medical solution?

What is asbestos?

Asbestos is a naturally occurring mineral that was long ago found to have fire retardant properties. Since 1879 asbestos has been used in production of fire-retardant products such as bricks, pipe coverings, brake linings, ceiling tiles, floor tiles, fire-resistant work clothes and many others. Because in its raw state asbestos is friable - meaning easily broken into microscopically small pieces by ordinary hand action - asbestos can be inhaled into the lungs and cause damage. Individual asbestos fibers are very small, with a width much smaller than a human hair.

When asbestos is not friable - such as when embedded in ceiling tiles or completely encased in pipe coverings - it cannot be inhaled and cause damage. Asbestos-containing materials are known as ACMs. ACMs, when broken up by machines, cut, scraped, or sanded, can release friable asbestos into the air.

Six naturally occurring minerals are considered "asbestos". Three were commonly used in various products (chrysotile, amosite and crocidolite). Three other asbestos minerals were uncommonly used (tremolite, actinolite, anthophyllite) and are rarely found today.

Form Chemical Formula Shape
(accounts for 90% of asbestos in products)
3MgO-2SiO2-2H20 white, curly

(serpentine family)

amosite (FeMg)SiO3 brown or gray, straight (amphibole family)
crocidolite Na2O-Fe2O3-3FeO-8SiO2-H2O blue, straight
(amphibole family)

Today only chrysotile - so called "white asbestos" - is mined and incorporated into products. However, since asbestos is indestructible, older buildings and products (pre-dating 1970s) may also contain some amosite (brown/off-white) or crocidolite (blue) asbestos.

What are ferruginous bodies?

Individual asbestos fibers cannot be seen under the ordinary (light) microscope. However, once in the lungs, a portion of asbestos fibers usually becomes coated with material that contains iron. The scientific name for things containing iron is "ferrous"; hence these coated fibers are called ferruginous bodies. An individual ferruginous body has a much greater mass than the uncoated fiber, and as a result can be seen under the light microscope. Ferruginous bodies are often looked for in lung tissue to prove asbestos exposure, and when found are sometimes referred to as "asbestos bodies." However, asbestos is not the only fiber that may be coated with iron; glass and cotton fibers, talc and graphite can also become coated with iron, and when this happens they are indistinguishable (under the light microscope) from true asbestos bodies.

Some asbestos claims revolve around the presence or absence of asbestos bodies in lung tissue. Any interpretation of this finding (presence or absence) must be balanced with the claimant's exposure history and associated lung pathology.

What is the harm from inhaling asbestos?

Because friable asbestos can be inhaled, the main medical concern is lung or respiratory disease. Disease can come about because of the body's reaction to the inhaled asbestos, which can be the formation of scar tissue. When scar tissue forms it replaces normal lung tissue; extensive amounts of scar tissue in the lungs can interfere with breathing. In addition, asbestos scar tissue in the lungs can lead to lung cancer.

Generally, asbestos respiratory diseases take two or more decades to develop from the time of exposure, and then only after extensive and long term exposure to friable asbestos. The more extensive and longer the exposure, the more risk an individual has for developing asbestos-related disease years later.
References for this question

Who is at risk for asbestos-related disease?

Asbestos is so ubiquitous we are all exposed to it in minute quantities. However, to develop disease one must have substantial exposure to friable asbestos. Usually, such exposure requires working with the friable product over a long period of time. At risk are workers in various occupations that exposed them to friable asbestos, in most cases, over many years. Examples of workers at risk are listed in the box.

  • Miners of asbestos
  • Shipyard workers
  • Powerplant workers
  • Brake lining workers
  • Pipe fitters
  • Insulators
  • Boiler makers and repairers
  • Maintenance workers (sometimes called millwrights) who worked in areas of the factory where friable asbestos was present
  • Workers in the production of fire bricks, fire-retardant paints, asbestos cement, and other asbestos-containing products

It should be noted that, while asbestos exposure occurs almost exclusively in the work place, it also may occur outside the workplace, such as in neighborhoods near asbestos mines. There are also several instances of worker's wives developing asbestos disease because they cleaned their husbands' asbestos-covered work clothes.
References for this question

What are the asbestos-related lung and respiratory diseases?

Five main respiratory diseases or conditions may occur from asbestos exposure (see Table). All of these diseases or conditions also have other causes; the patient's asbestos exposure history and specific features of the diagnosis often suffice to implicate asbestos as a cause. In many cases however, the role of asbestos in causing the problem may be in doubt and will be disputed.

Asbestos-related diseases or conditions
Disease or condition Other causes besides asbestos Comment
Interstitial fibrosis Over 100 asbestosis when cause is asbestos
Pleural plaques/fibrosis Several Best visualized on a chest CT scan.
Benign pleural effusion Many Rarely from asbestos
Lung cancer Cigarettes alone in >90% of cases Asbestos synergistic with cigarettes
Malignant mesothelioma About half the cases are of unknown cause Asbestos assumed cause if there has been documented remote exposure

Interstitial fibrosis.Lung tissue is very thin, delicate tissue that consists of millions of air sacs surrounded by blood vessels and connective tissue; that portion of the lungs surrounding the air sacs is collectively called the "interstitium." If scarring occurs in the interstitium it is called interstitial fibrosis. Now if thin asbestos fibers are inhaled and get into the interstitium they can be a cause of this fibrosis. When this occurs the patient has asbestosis, i.e., intersititial fibrosis from inhaled asbestos. Interstitial fibrosis can actually occur from many products and diseases (well over 100), and is by itself a non-specific disorder; other causes include drug reactions, infections, arthritis-related diseases, and chronic heart failure. Again, asbestosis is interstitial fibrosis specifically due to inhaled asbestos. Like any case of interstitial fibrosis, asbestosis can lead to shortness of breath and ultimately be fatal.
References for this condition

Pleural plaques and pleural fibrosis. Sometimes the scarring is not in the lung tissue itself, but in the outside linings of the lung, called the pleura or pleural membranes. These are thin, glistening membranes that completely cover the lungs. When visible on a chest x-ray, this scarring is termed pleural plaques or pleural fibrosis. However, they are often difficult to discern on plain chest x-ray, and are much better vizualized on a chest CT scan.

Disease confined to the pleural membranes is not asbestosis, a mistake in diagnosis frequently made by physicians reading chest x-rays. Unlike asbestosis, pleural plaques and fibrosis rarely cause symptoms or any discomfort. Sometimes calcium is deposited into these plaques, and then they are much more easily seen on chest x-ray (because calcium is so dense). Several other conditions can cause pleural scarring and calcium deposits, such as healed tuberculosis and other infections. However, a particular distribution of pleural plaques/fibrosis on the chest x-ray (for example, covering both diaphragm muscles, especially if calcified) can be attributed to asbestos, if there is a history of exposure and no other cause is evident.
References for this condition

Benign Pleural effusion. Pleural effusion - a collection of fluid around the lung - is a very common medical problem; like interstitial fibrosis, there are many potential causes (e.g., pneumonia, congestive heart failure, cancer, kidney disease, rheumatoid arthritis, tuberculosis). Asbestos can cause two very different types of pleural effusion - benign and malignant. Benign pleural effusion is a frequent condition, but is only rarely from asbestos. Malignant pleural effusion can be due to either lung cancer or mesothelioma, conditions which are discussed separately. Benign pleural effusion, when attributable to asbestos, is presumably due to inflammation generated by reaction to asbestos fibers. When the pleural fluid becomes substantial (usually over a pint or 500 cc's) the patient may have symptoms (usually shortness of breath) and the chest x-ray will show the fluid collection. Asbestos is actually a rare cause of pleural effusion (pleural scarring and pleural plaques are a much more common result of asbestos inhalation). The only way to to reliably diagnose most causes of pleural effusion is to sample the fluid via a needle in the pleural space, and examine it in the lab. This is an invasive procedure (because it involves a needle) called 'thoracentesis', and is routinely performed in hospitals.
References for this condition

Lung cancer. Lung cancer is the most difficult disease to attribute to asbestos for one principal reason: Over 90% of lung cancers are due to cigarette smoking and virtually all lung cancer patients with asbestos exposure also have a strong smoking history. (In over two decades I have come across only one case of lung cancer in an asbestos worker who never smoked.) Lung cancer is common, with about 180,000 new cases a year in the U.S. Since we know asbestos is potentially carcinogenic, every patient with lung cancer and a history of friable asbestos exposure should be evaluated to see what role, if any, asbestos played. Lung cancer in patients with a history of asbestos exposure frequently leads to litigation. The litigation often ends up pitting expert against expert, all quoting from the abundant literature on the subject (see references). This point is discussed further in What is the Browne Hypothesis?
References for this condition

Malignant Mesothelioma. This is cancer of the thin membranes that surround the lungs and abdominal organs. Malignant mesothelioma occurs much more commmonly in the chest than in the abdomen. Asbestos-caused mesothelioma in the abdomen is thought to arise from fibers entering the lungs and then penetrating through the diaphragm muscles.

Fortunately, mesothelioma is a rare cancer, affecting only about 2000 people a year in the U.S. Unlike lung cancer, it is not due to smoking; in fact, the only known cause of mesothelioma in this country is remote asbestos exposure (there are other, rare causes of mesothelioma, such as the fibrous material "erionite," mined in Turkey). The lag time from first exposure to diagnosis is 20 to 40 years. However, in about half the cases there is no history of asbestos exposure, and the cause is unknown. A documented history of asbestos exposure and the diagnosis of malignant mesothelioma will invariably be linked, so in the area of asbestos litigation these cases are straightforward -- medically, at least.
References for this condition

Are asbestos-related diseases treatable?

Asbestosis is not treatable, although symptoms in the worst cases can be ameliorated with oxygen, steroids and other measures.

Pleural plaques and pleural fibrosis are also not treatable, but they generally cause no symptoms or discomfort.

Pleural effusion is treatable with removal of the fluid; if the fluid comes back, there are procedures that can be taken to keep this from happening.

Lung cancer is curable only by removing the cancer through surgery; however, at the time of diagnosis most lung cancers can't be removed, and then treatment will be with radiation or (less commonly) chemotherapy. Radiation and chemotherapy are considered palliative, as they rarely will cure lung cancer, only slow it down.

Mesothelioma is not resectable, since it involves the lining of the lung and the adjacent chest wall. Rarely, in highly selected cases, a few surgeons will attempt to remove the entire lung with its lining and parts of the chest wall; this procedure, called "radical pneumonectomy", might prolong survival in a few individuals but is not an option for most patients. Radiation and chemotherapy are not effective for mesothelioma, and most patients succumb within 12 months of the diagnosis.

What are the symptoms of asbestos-related lung disease?

The symptoms are the same as would be seen in any cause of interstitial fibrosis, pleural plaques/fibrosis, benign pleural effusion, lung cancer or mesothelioma, and generally depend on two factors:

  • extent of the disease, both within the chest (usually determined from the chest x-ray or CT scan) and, for cancer, spread to other parts of the body;
  • co-existing conditions, such as smoking-related lung disease.

In early interstitial fibrosis there are usually no symptoms, but as the disease advances shortness of breath is the principal complaint.

Benign pleural effusion is asymptomatic when the amount of fluid is small, but in moderate to large effusions shortness of breath is common; sometimes patients can also complain of chest pain worse with a full breath (so-called pleuritic pain).

Lung cancer causes no symptoms in the early stages, even though it may be seen on chest X-ray. In fact, by the time the cancer does cause symptoms it is usually far advanced. Symptoms from lung cancer can include shortness of breath, coughing up blood, and chest pain. (If lung cancer has spread outside the chest it can cause other symptoms, depending on location.)

Mesothelioma generally causes symptoms earlier than lung cancer, because it grows between the lung and the chest wall, an area more sensitive to pain than inside the lung (where lung cancer starts). As a mesothelioma grows it can cause shortness of breath, chest pain, decreased appetite and weight loss.

Pleural plaques/pleural fibrosis cause no symptoms unless the amount of scarring is very extensive, over both lungs; then it can cause shortness of breath. However, extensive scarring of the pleura from asbestos is rare, so the vast majority of workers with pleural plaques/pleural fibrosis have no symptoms.

In summary, the main symptom from asbestos-related lung conditions is either "none" or "shortness of breath." The medical term for shortness of breath is dyspnea. Dyspnea is such a common symptom, with so many causes, that it has no specificity by itself. Given a randomly-chosen, middle-aged man who was exposed to asbestos in the past, any shortness of breath he has is statistically most likely from a non-asbestos-related condition. The most common causes of dyspnea in this population: poor physical fitness with or without obesity; smoking-related lung disease; and heart disease.

How does smoking affect asbestos diseases?

Smoking does not cause asbestosis, pleural scarring, pleural effusion or mesothelioma. However, there is some evidence that smoking - since it affects the lungs' natural protective mechanisms - makes people more vulnerable to inhaled asbestos and more likely to develop asbestosis. Also, a patient with any asbestos-related disease might have shortness of breath due to mainly or exclusively from his smoking-related disease.

Many workers who were exposed to asbestos were also heavy cigarette smokers. Because the latency of asbestos-related diseases is 20 years or more, by the time these workers are checked for asbestos diseases they often have a very long smoking history and therefore smoking-related disease -- principally chronic obstructive pulmonary disease (COPD). COPD includes two separate pulmonary diseases, which commonly overlap in a given patient - chronic bronchitis and emphysema. Chronic bronchitis and emphysema are just different manifestations of lung damage from smoking.

Smoking is also the major cause of lung cancer. Since both asbestos and smoking can independently cause lung cancer, it is obviously important that anyone who might have been exposed to friable asbestos never smoke. Smoking not only adds to lung cancer risk in some asbestos workers, it can heighten the risk -- a process known as synergism. This has been demonstrated with certainty only if the worker has lung scarring from asbestosis. Synergism means that if, for example, the risk of developing lung cancer from asbestosis is 1% and the risk from smoking is 2%, that the risk in the smoking asbestosis patient is significantly higher than 3%.

One of the most contentious areas in asbestos claims is whether mere asbestos exposure -- without any apparent scarring in the lungs -- also acts synergistically with smoking to increase lung cancer risk. The published evidence suggests that it does not. This point is discussed extensively in What is the Browne Hypothesis?
References for this question

What other diseases can occur from asbestos?

Rarely, patients can get mesothelioma in the abdomen from inhaled asbestos. Other conditions often attributed to asbestos, like colon cancer and throat cancer, are unproven and so are often the subject of litigation when they occur. Common respiratory illnesses like asthma, sinusitis, bronchitis, emphysema and pneumonia are not due to asbestos.

How is asbestos lung disease diagnosed?

There must be a history of substantial exposure to friable asbestos AND a lung condition that could be related to asbestos exposure AND no evidence for another cause. For example, a positive exposure history plus interstitial lung disease on chest x-ray plus the absence of any other cause, would be a presumptive diagnosis of asbestosis. However, note that:

  • A history of asbestos exposure, without a documented lung condition related to asbestos exposure = no diagnosis of asbestos-related disease. Example: A 65-year-old man with a history of asbestos exposure and a previously clear chest x-ray suddenly develops pulmonary edema (water in the lungs); his pulmonary condition is not one related to asbestos exposure.

  • No history of asbestos exposure, with a condition that could otherwise be due to inhaled asbestos = no diagnosis of asbestos-related disease. Example: A 45-year-old woman with no history of asbestos exposure develops malignant mesothelioma. This pulmonary condition is commonly linked to asbestos exposure, but absent such history the cause in her case remains unknown.

The vast majority of asbestos lung diseases occur from remote exposure at the workplace. Given a documented history of asbestos exposure, there are three ways to diagnose asbestos lung disease:

  • A chest x-ray or chest CT scan (more detailed than a regular chest x-ray) diagnostic of or consistent with an asbestos-related condition.
  • A lung biopsy diagnostic of an asbestos-related condition.
  • An autopsy diagnostic of an asbestos-related condition.

Well over 95% of cases can be diagnosed with just the history of friable asbestos exposure and an abnormal chest x-ray or chest CT scan. It is rare to make the diagnosis using lung tissue or autopsy, because these exams are rarely obtained.

Obtaining a portion of lung tissue usually requires surgery. While tiny pieces of lung tissue can be obtained without surgery (through an instrument called a bronchoscope), they are usually too small to diagnose asbestos-related diseases. When lung tissue is available the pathologist will look for ferruginous bodies (see What are ferruginous bodies?) as well as other signs of asbestos-related pathology. Surgical removal of lung tissue obviously presents some risk to the patient, and won't be attempted unless there is perceived benefit. For example, since asbestosis is not treatable, physicians won't recommend an operation if they strongly suspect only this condition. On the other hand, a patient may have surgery to remove a lung cancer, and then there will be sufficient lung tissue to also look for asbestosis.

Autopsy is even rarer than operation for lung tissue, because most diagnoses are made while the patient is living. Also, the vast majority of deaths are no longer autopsied in this country. In fact, most families of asbestos-exposed workers refuse permission, even though an autopsy, because it allows for complete examination of both lungs, would definitively make the diagnosis if the disease is present.

Why is there so much argument over asbestos?

"Asbestos" is a term fraught with dispute. Decades ago it was a widely-used mineral in thousands of manufacturing processes, with no hint of the dangers it might impose. Today its use is highly constricted, in this country only to chrysotile, and then only in selected products. There are few parallels to the changed perception of asbestos in just a few short decades. (The closest parallel is cigarettes; another might be nuclear power plants.)

Like tobacco companies, asbestos manufacturers knew more about the harm of their product than they admitted, and they did not take proper safeguards to protect the people most exposed (in this case blue collar workers, not consumers of the product). Then, when workers started developing disease years after exposure, numerous law suits ensued, eventually putting many companies out of business. (See Kook Sim, 2001 in References). When all or virtually all people truly sick with asbestos disease either died or were compensated, attorneys sought out workers not sick but who might have been exposed to asbestos in their factory work; this process quickly morphed into what is now known as the United States Asbestos Screening Scam.

A result of all this activity is tremendous polarization on the subject. On the web you will find (as expected) widely divergent viewpoints, from The National Association of Manufacturers to the "American Association for Justice" (new name for the Association of American Trial Lawyers).

Underlying disputes in each claim (see next two questions) are fundamental philosophical differences between plaintiff lawyers and defendants. Plaintiff lawyers believe the asbestos industry -- companies engaged in mining, manufacturing or supplying the product -- should pay every worker ever exposed to asbestos, irrespective of the worker's medical condition (in other words, pay the lawyers who solicited these workers to file claims). To this end the plaintiff's bar conducted seminars on how to file claims when there is no demonstrable medical condition (Schmitt 2001).

The defendants of asbestos claims -- as well as many judges, congressmen and physicians - feel this is an untenable position, self-serving only for the lawyers, and that only workers who actually have demonstrable asbestos-related disease should be compensated.

Anyone involved or who plans to become involved in asbestos disease evaluation should understand this fundamental philosophical rift, as it helps explain claims when they are made up or 'manufactured'. To get their foot in the legal door the attorneys and a hanful of physicians simply made up hundreds of thousands of claims. But that's just a cover for getting into court and making money. For plaintiffs' lawyers, the reports their physician experts provide -- again, almost all of them medically bogus -- are merely a means to one of two ends. First, and preferable, is to obtain mass settlements; a few legitimate cases are bundled with the bogus claims, and defending companies often settle the whole lot without investigating the merits of individual cases.

Second, if a defending company chooses to fight a case to trial, the plaintiff's lawyers are then fully prepared to proclaim the sins of asbestos suppliers, and argue that these sins justify compensation for any worker exposed to asbestos in the past regardless of the medical condition. In other words, Doctor A may say asbestos disease and Doctor B may say there is none, but the "sins" and the "worker's exposure" will be argued as equally (if not more) important issues.

See United States Asbestos Screening Scam and
Additonal references for this question

What are the principal disputes in asbestos-related claims?

In this context, "claim" means that an individual or his estate:

  • is claiming he was exposed to asbestos, and
  • has (or had if deceased) a condition or disease arising from such exposure, and
  • is demanding another party pay him (or his estate) money for the disease or condition.

The demand could be against a company, a state worker's compensation board or a bankruptcy court. Most asbestos claims are disputed because of disagreement over one or more of the following:

  • the claimant's asbestos exposure history
  • the responsible company or companies
  • the diagnosis

The first and second disputes don't involves physicians, since they are based on employment records, job descriptions, co-worker affidavits, plant documents, previous court documents, etc. The third dispute always involves physicians, one way or another, because lawyers need physicians to read the chest x-rays and state the medical diagnosis.

What are the specific reasons for most asbestos litigation?

Since there is no specific treatment for asbestos-related disorders, disagreements about diagnosis would be only "academic" if there were no legal claims. However, since most asbestos diagnoses are linked to monetary claims at some point, dispute is inevitable. Here are the most common specific reasons for asbestos litigation.

  • For many years the hazards of asbestos were known by companies involved in its mining and manufacture, but proper safeguards were not taken to protect workers. For this reason any worker who later develops an asbestos-related condition can make a claim against the miner/manufacturer. In other words, the worker can claim that he was exposed unnecessarily to an unsafe product, and that the product caused disease.

  • Asbestos-related conditions have a long latency period, often two decades or more after first exposure before a condition becomes manifest. Because many companies once in the asbestos business have merged or gone out of business, it is often difficult to even identify the responsible company years later, when a claim is filed. Company X may be sued, but argue that it was really company Y that supplied the asbestos 30 years earlier. Or, several companies may have supplied the asbestos, and end up litigating over who supplied what proportion for which factory process.

  • Even when the responsible company is known, the worker still must prove he was exposed to friable asbestos in the workplace, and in sufficient amount to have caused the condition. Yet job descriptions are often sketchy or non-existent decades later. Many times the claimant is deceased, and the lawsuit is brought by the widow or the estate; in those situations co-worker affidavits are often used to establish work place exposure for the deceased. Understandably, companies often dispute the exposure history.

    Since World War II many people have worked in factories where asbestos was present, but it was not necessarily friable asbestos. For example many plants had, and continue to have, pipes covered with asbestos but wrapped so that no friable asbestos is released. If the worker's job was to cut, repair and replace these pipes all day long, chances are good he would be exposed to much friable asbestos during his career. Now suppose another worker drove a tow motor in the same plant and was never exposed to the pipes except in their intact state.

    Any lung condition that the first worker developed would have to be closely examined for an asbestos cause. Any lung condition that the second worker developed would be unlikely related to asbestos. The fact is, in many cases we don't know exactly what, or to what extent, workers were exposed to decades ago. In places like Canada and Montana, where there are asbestos mines, exposure history is often more apparent than in most American factories.

  • Lung cancer is almost always due to smoking, and virtually every ex-asbestos worker with lung cancer is a smoker or ex-smoker. All experts believe that asbestos is contributory when there is definite asbestos scarring (asbestosis) along with the lung cancer. Many researches feel that one must demonstrate radiologic or histologic (on lung tissue) asbestosis to link asbestos exposure as a cause of lung cancer (the Browne Hypothesis). Understandably, other researchers disagree, and this point is often the subject of debate - and a reason for litigation - in lung cancer claims.

  • Even granted that a patient's lung cancer was due to both asbestos and smoking, different courts treat this information differently. Some award maximum damages if asbestos was any percentage of the cause; others only award compensation based on the percentage attributed to asbestos, a percentage which is subject to wide interpretation.

  • Pleural plaques are almost never associated with any physical impairment. Controversy arises over whether they are associated with increased risk of developing lung cancer. (See next two questions).

  • Mesolthelioma is invariably linked to asbestos if exposure can be documented. When cause and effect is so clearly established, attorneys for patients usually seek jury trial to maximize the award.

  • The American Thoracic Society formulated standard criteria for the diagnosis of asbestosis, which were published in the mid 1980s. However, many physicians feel they are too restrictive and will argue a more liberal diagnosis in court.

  • Claims based only on the chest x-ray are the most common type of claim today. Since these cases were solicited by plaintiff's attorneys from union rolls, the sued companies often hire their own physicians to examine the claimants. The companies' experts often disagree with physicians hired by plaintiff's attorneys.

Why is There Controversy over Diagnosis of Pleural Plaques?

Pleural plaques from inhaled asbestos are relatively common (compared to other asbestos-related conditions), and are benign. In one study of asbestos- exposed factory workers who had pleural plaques, the size of the plaques averaged 47.9 sq. cm, or 2.4% of the typical pleural surface of 2000 sq. cm. Interestingly, the size of the plaques was not related to asbestos exposure intensity. Also, the lung function of workers with pleural plaques was the same as a comparable group of workers with no plaques or history of asbestos exposure (Van Cleemput 2001).

Though a marker of remote asbestos exposure, plaques are sometimes difficult to diagnose on a plain chest x-ray because other shadows (particularly overlying body fat) may confuse the picture (Muller 1993). This is particularly true if the plaques are not calcified. While a chest CT scan can usually separate out pleural plaques from other shadows, CT scans are not routinely done in most asbestos claimants. Most claims filed for pleural plaques are based on the chest x-ray alone, resulting in much interpretive controversy.

Though a marker of remote

References for this question

Do Pleural Plaques Lead to Cancer?

The only way to answer a question like this one is by population studies, i.e., identifying a group with and without pleural plaques, and then following each group for a long period of time. However, since lung cancer is almost always due to smoking, and since most asbestos-exposed workers have a smoking history, the two groups must be carefully controlled for smoking as well as other variables like how the initial chest x-ray was interpreted (see above question), the subjects' age, and any associated lung conditions. Published studies show either no relationship between plaques and cancer, or suggest a slight statistical association. Not unexpectedly, experts can select studies to support both sides of the issue.

In one population study suggesting a relationship between pleural plaques and cancer, Hillerdal wrote (1994):

"From the general population in the county of Uppsala, Sweden, 1,596 men with pleural plaques fulfilling strict radiologic criteria were identified from 1963 until June 1985. The men have been followed prospectively for 16,369 person-years...The risk for patients with pleural plaques without asbestosis was increased 1.4 times, which was statistically significant."

An opposing editorial in the same journal (Smith 1994) was highly skeptical of Hillerdal's findings, as well as other studies on the subject. Smith pointed out the difficulty of quantitating asbestos exposure and true smoking histories, and of even confirming pleural plaques on the chest x-ray. After providing numerous citations and cogent arguments against Hillerdal's findings, Smith wrote:

"The study of Hillerdal does not demonstrate a significant enough increase in risk to overcome the experimental limitations in his study. This study is just another study that has failed to demonstrate convincing evidence of a significant risk of lung cancer associated with pleural plaques without asbestosis."

References for this question

What is the Browne Hypothesis?

In 1986 Dr. K. Browne published a paper in the British Journal of Industrial Medicine titled: Is asbestos or asbestosis the cause of the increased risk of lung cancer in asbestos workers? Dr. Browne's basic conclusion was that asbestos per se may not be completely carcinogenic:
"neoplastic change [cancer] may appear only in the wake of inflammation and subsequent is not asbestos per se but asbestosis which prepares the soil for subsequent malignancy."

This assessment was based on epidemiologic and biological evidence that lung cancer in asbestos exposed workers was due to asbestosis and not to asbestos exposure per se. This hypothesis, to put it mildly, is hotly debated. The implications are obvious. If Browne's hypothesis is accepted, then simply being exposed to asbestos is not enough to implicate asbestos as a cause of cancer; the history of smoking (almost always present in lung cancer patients claiming an asbestos cause) should be sufficient to explain the cancer. If Browne's hypothesis is not accepted - if the worker has no evidence of an asbestos-related disease, but merely the history of exposure - then asbestos could be claimed as a co-contributor to lung cancer, along with cigarettes.

Since 1986 dozens of articles have appeared favoring or disputing the Browne Hypothesis. The issue was put into perspective by a review in the British medical journal Thorax (Jones 1996). After surveying the literature the authors wrote:

"Asbestos is the most studied of all occupational carcinogens and, apart from tobacco, the most studied cause of lung cancer. It may therefore surprise the general reader that there is an important area of uncertainty about the relationship between inhaled asbestos and the resulting increase in risk of lung cancer. At issue is whether asbestos-attributable lung cancers are always associated with asbestos-induced lung fibrosis -- that is, asbestosis. This uncertainty has engendered a heated controversy, fuelled by important implications for regulation, workers' compensation, and litigation." (Page S9)

Jones, et. al. summarized their assessment of the issues as follows (page S14).

  • "Lung fibrosis of many causes - known and unknown - is associated with increased risk of lung cancer.
  • The much discussed synergism between asbestos "exposure" and smoking found in mortality studies of insulation workers turns out to be a synergism involving asbestosis, not just asbestos exposure.
  • The site of origin and cell type of a lung cancer are not regarded as reliable indicators of causation (or non-causation) by asbestos.
  • In asbestos inhalation experiments animals develop excess lung tumours only when lung fibrosis is also produced.
  • Pleural plaques have not proved to be a reliable marker for increased risk of lung cancer.
  • Excess lung cancer deaths in populations exposed to asbestos are generally first detected at about the same cumulative exposure levels as those at which asbestosis begins to appear."

In 1999 Dr. William Weiss reviewed 39 English language reports of cohorts exposed to asbestos in an attempt to address this question. In his paper, Asbestosis: A Marker for the Increased Risk of Lung Cancer Among Workers Exposed to Asbestos, Weiss wrote:

"The adequately designed studies in the literature support [the Browne] hypothesis. The summary relative risk for lung cancer was 1.00 in seven cohorts with no deaths from asbestosis. In addition, there is a high correlation between asbestosis rates and lung cancer rates in 38 cohorts in contrast to a poor correlation between cumulative exposure data and lung cancer relative risks in eight cohorts with adequate data. The evidence indicates that asbestosis is a much better predictor of excess lung cancer risk than measures of exposure and serves as a marker for attributable cases."

Recognizing the controversy involved, the editors invited an editorial response to Dr. Weiss's paper, in which other physicians wrote:

"Asbestosis is an indicator of high exposure and contributes additional risk to lung cancer beyond that conferred by sufficient asbestos exposure alone. In our opinion, the hypothesis that the excess lung cancer risk in worker cohorts exposed to asbestos occurs only among those with asbestosis is insufficient to explain this heightened risk of carcinogenicity."

Even accepting the Browne Hypothesis, the problem still arises as to how one defines and diagnoses asbestosis. As already pointed out, physicians hired by plaintiff attorneys are much more liberal in their definitions than are most other physicians.
References for this question

What are the standard criteria for diagnosing asbestosis?

In the mid 1980s the American Thoracic Society helped formulate criteria for diagnosing asbestosis. In the ATS medical journal a group of experts proposed the following criteria for diagnosing asbestosis (Murphy 1986; here paraphrased).

  • A definite history of exposure to friable asbestos
  • A definitely, unequivocally abnormal chest x-ray showing changes typical of asbestosis
  • A definitely abnormal breathing test, showing a certain degree of impairment that could be due to asbestos inhalation.
  • Findings on physical exam of the lungs compatible with the diagnosis, and not due to some other condition.

Physicians adhering to these criteria would obviously not diagnose asbestosis in patients with only subtle shadows on chest x-ray, or with normal lung function tests, or with another diagnosis (e.g., congestive heart failure) to explain any abnormalities.

The authors of the ATS article recognized that true asbestosis is a serious disease, for which there is no effective treatment. Patients are short of breath, at least on exertion. They have abnormal chest x-rays. They have abnormal breathing tests. The authors specifically chose not let the diagnosis encompass 'healthy' people with equivocal chest x-rays.

Then in September 2004 the American Thoracic Society published a long awaited update on diagnosis of nonmalignant asbestos diseases. Authored by 11 physicians, it appeared in the ATS publication, Journal of Respiratory and Critical Care Medicine (AJRCCM). The update covered developments over the prior 2 decades and offered guidelines for diagnosis. However, the ATS dropped its scientific objectivity, and made statements regarding x-ray diagnosis that were (and are) unsupported (indeed contradicted) by the peer-review literature at the time; indeed, the statement omitted numerous key references. The result was a paper in which the authors evidenced bias in favor of mass screenings by plaintiff-attorney-hired physicians (PAHP), the same physicians who helped create the United States Asbestos Screening Scam.

The vast majority of asbestos disease diagnoses by PAHP have been discredited as non-objective, but this is not mentioned in the ATS statement. Instead, the authors assumed PAHP diagnoses are valid in making their recommendations. Apart from inherent bias in the article's content and presentation, AJRCCM also violated its own ironclad policy by not publishing the authors' conflict of interest statements. Only after I wrote a letter to the editor did they belatedly publish these statements. Click here for details about this flawed 2004 ATS statement on asbestos disease diagnosis.
More references for this question

What are the Helsinki Criteria?

In January 1997 a group of experts met in Helsinki, Finland to "discuss disorders of the lung and pleura in association with asbestos and to agree upon state-of-the-art-criteria for their diagnosis and attribution with respect to asbestosis." Their report, nicknamed The Helsinki Criteria, was published in a Scandinavian medical journal (see References).

Prior to the Helsinki Criteria the only published consensus report about clinical diagnosis of asbestos diseases was the American Thoracic Society article published in 1986 (see above). Unfortunately, the Helsinki report does not refer to the ATS article; also, it does not offer any new research or even any references to earlier research or opinion. For these reasons the Helsinki report does not replace the 1986 ATS report, and is at best an editorial comment by a group of international experts.

Principal points raised in the Helsinki Criteria article include:

  • Reliable work histories provide the most practical and useful measures of occupational asbestos exposure;
  • High resolution CT scan can facilitate detection of asbestosis and asbestos-related pleural abnormalities, but is not recommended as a screening tool;
  • New imaging techniques (MRI, gallium scanning, PET scanning) are not recommended for clinical diagnosis;
  • Radiologic findings of small opacities, ILO grade 1/0, "are usually regarded as an early stage of asbestosis." (A score of "1/0" means the first impression is there is some scarring (1)/but a second impression is that the film may also be negative, that is, show no scarring (0).)

This last point is in contrast to the ATS report, which opined that the threshold of diagnosis should be a radiologic score of 1/1 (both the first and second impression is that there is some scarring on the chest x-ray). However, the Helsinki report also states that "Smoking effects should be considered in the evaluation of early asbestosis." This is a very important point often overlooked by people interpreting chest x-rays of known asbestos claimants.
References for this question

How are claims based only on the chest x-ray?

To understand this situation, you must first understand that medical diagnosis of many conditions is often imprecise, or is based on imprecise tools. Asbestosis is defined as lung tissue scarring from inhaled asbestos. Pleural plaques/fibrosis is scarring of the lining of the lungs. These definitions seem straight forward, but how do we actually diagnose this scarring? As already pointed out, direct examination of lung tissue for evidence of asbestos scarring (lung biopsy and/or autopsy) is rarely performed. Instead, the vast majority of cases are diagnosed by "shadows" seen on the ordinary chest x-ray or chest CT scan (performed much less commonly than the chest x-ray). In this sense the diagnosis is usually inferential.

Inferential diagnosis is accepted when you have a classic presentation - unequivocal exposure history, unequivocal chest x-ray. But the vast majority of the unequivocal patients were long ago diagnosed and compensated. What is left now are tens of thousands of workers and ex-workers whose exposure history and chest x-ray are far from unequivocal. Their cases are, in fact, very equivocal. And when you start with equivocal abnormalities on a chest x-ray, you are entering the realm of subjective interpretation, of inherent biases, of one doctor's opinion vs. another's (it is only physicians who are trained to interpret chest x-rays). For this reason, in most current claims there is often significant disagreement over chest x-ray interpretation and, ultimately, diagnosis.

Years ago the U.S. Department of Labor set up a special program to train physicians to read chest x-rays of workers (principally coal miners) exposed to coal and silica dust. (Coal miners can develop a disease from inhaled coal and silica dust known as "black lung".) The goal of the training program was to bring some standards to the reading of these workers' chest x-rays, and to identify the workers with early dust disease. Because these physicians passed 'Part B' of DOL's training course, they are collectively known as 'B-Readers.'

Now it turns out that coal, silica and asbestos dust can give similar appearances on the chest x-ray. For this reason B-Readers are usually called upon to read the chest x-rays of asbestos workers. It is now practically a legal requirement that any asbestos claim (based on chest x-ray) be certified by a B-reader. Yet studies have shown that B-Readers as a group display enormous variation in chest x-ray interpretation.

The problem is manifest most acutely in the hundreds of thousands of claims that started with screening chest x-rays. In this situation there are no real patients, no pre-existing diagnoses in people who worked around asbestos; instead, there are attorneys looking for claimants. In the 1980s and early 1990s plaintiff's attorneys visited unions of many plants known to have used asbestos in the past. Working from union rolls, the attorneys then offered free screening chest x-rays to tens of thousands of factory workers and ex-workers with one goal in mind -- to look for asbestos-related disease in order to file mass claims. (For a succinct history of asbestos litigation, see A History of Asbestos Use and Asbestos Litigation and Asbestos Litigation History.)

The result of these mass screenings has been the largest legal scam in the nation's history, exhaustively documented in references available at The United States Asbestos Screening Scam. Plaintiff attorneys may try to justify this solicitation as an important service to the workers, since previously-unrecognized asbestos disease could be a precursor to crippling disease later on. Since a chest x-ray is harmless, and there is no up front cost to the workers, most of them signed up for the program (in many cases a breathing test was also done). But the whole process was fraudulent from the getgo, and cost the U.S. hundreds of thousands of lost jobs and bankrupted dozens of companies.

It worked this way. The attorneys then sent the chest x-rays to B-Reader physicians hired specifically to interpret them. These B-Readers - who never saw the workers and had no direct knowledge about their asbestos exposure or medical history -- read the chest x-rays looking for asbestos-related disease. In fact, physicians hired by the attorneys are paid extra to find asbestos disease, and in some cases a particular chest x-ray will be shopped around to other B-readers until the attorney gets the reading desired (small opacity profusion of 1/0 or greater, or evidence for pleural plaques/thickening). (See Egilman D. Asbestos screenings. Amer J Indust Med 2002;42:163).

Physicians reading the x-rays send their reports directly to the attorneys. When their reports indicated the possibility of asbestos disease, a lawsuit was filed on behalf of the worker against all the known asbestos suppliers of the worker's plant. Subsequent analysis of these cases -- on an individual basis, by other physicians -- shows that these attorney-generated chest x-rays were (and are) over interpreted for asbestos-related disease the vast majority of time.

Smokers, in particular, can have subtle "opacities" on chest x-ray that are often mis-interpreted as due to asbestos disease. Such mis-interpretation can be shown with a high resolution CT scan. Also, many other diseases can manifest x-ray changes similar to asbestos-related disease; without proper investigation these cases are erroneously assumed to be asbestos-related, but that's all part of the scam. There was never any intent to be thorough or objective in the hundreds of thousands of claims generate by plaintiff attorneys.

See The United States Asbestos Screening Scam, plus
Other references for this question

What results from claims based only on the chest x-ray?

There are so many attorney-generated cases filed in the U.S. that no one judge or court system has a handle on them all. There is currently a huge backlog of claims. Each worker may file claims against a dozen or more asbestos suppliers; the settling of a claim by one supplier does not eliminate outstanding claims against other suppliers. For companies that choose to defend themselves, it is expensive just to prove a worker doesn't have asbestos disease; proof involves hiring experts to examine the worker, obtain and interpret a new chest x-ray, file a report, etc.

Even though the vast majority of these claimants have no evidence for asbestos-related disease by objective criteria, it is usually cheaper to 'pay up' than to fight each case in court. As one corporation (USG) has publicly stated, "Many defendant companies have tens of thousands of cases filed against them by people who are not sick - those cases can usually be settled out of court for only a couple of thousand dollars per claim. To challenge each of these cases in court would cost many times more than the settlement cost."

Some workers are found with real disease, but not many. This is because most patients with real disease will have seen a physician, already had a chest x-ray, and if something was found filed a claim. Screening has uncovered a small percentage of abnormal chest x-rays which do reflect remote asbestos inhalation. But because these cases are lumped together with all the bogus claims, patients with undisputed disease (such as mesothelioma) tend to get short shrift, as some funds to pay their claims are apportioned for claimants without real disease.

Another result is that workers without symptoms or true abnormality on chest x-ray are subjected to numerous examinations, hearings, chest x-rays and doctor visits. Many have stated, spontaneously, that they wish they had never become involved in the process, since (so far) the monies received (by some company settlements) are small and the inconvenience not worth it. They understand that their claims serve mainly the attorneys who solicited them and that they are but pawns in the litigation.

Plaintiff's attorneys can claim, with some justification, that workers deserve to be compensated if they have asbestos lurking in their lungs, since they could develop real disease (e.g., cancer) at any time. If the attorneys truly uncovered many workers with a ticking time bomb, the mass effort would be justified. But the vast majority of claims have been filed for workers with no asbestos disease evident on the chest x-ray. How can this be?

The problem is in the interpretation of the chest x-ray. Smokers, in particular, can have "shadows" that are often mis-interpreted as asbestos disease. Also, many other conditions (e.g., congestive heart failure) can mimic chest x-ray changes that are mis-interpreted as due to asbestos. Remember, physicians reading the chest x-rays know nothing about the workers' individual medical histories.

Is there a solution to the asbestos-litigation problem?

The problem was no doubt more acute years ago, when tens of thousands of cases were filed and companies were forced into bankruptcy left and right. Then a huge scandal hit the asbestos-claim business in 2005, when very similar claims for silicosis were shown to have been a)bogus, and b)manufactured by the same groups (doctors and lawyers) who had manufactured thousands of asbestos claims. For information about this seminal event - see:
Bloomberg news article
NPR news story
Washington Examiner news article

Amazingly, the wholesale manufacture of bogus cases is still on-going. An editorial in the November 10, 2008 Wall Street Journal titled "Michigan Malpractice," opined on a mass tort claim there.

"One reason we know about the great silicosis legal scam is that a Texas judge was brave enough to expose doctors who'd been paid by tort lawyers to gin up phony diagnoses. So it is encouraging to see a Michigan judge now helping to expose evidence of similar medical fraud in asbestos claims. This action is taking place in the courthouse of Wayne County Circuit Court Judge Robert Colombo, Jr. Asbestos defendants have been attempting to disqualify...a physician who appears to have falsely diagnosed thousands of people with asbestos-related disease..."

Spurred on by courageous Judge Janice Jack in the silicosis cases, many courts have forced or are forcing plaintiff attorneys to drop their worthless (medically speaking) claims, and focus only on legitimate ones. For more publications since Judge Jack's 2005 court opinion, see The United States Asbestos Screening Scam,

Below is my proposal to fix the asbestos/silicosis litigation mess.

Proposal to Fix the Asbestos/Silicosis Litigation Mess

Two panels of expert physicians should be created: board-certified radiologists to interpret the chest x-rays, and board-certified pulmonary physicians to examine any claimants with truly abnormal films. Physicians comprising both panels would be agreed to before hand by both plaintiff and defense attorneys. As a practical matter, this would probably entail about 100 radiologists and 200 pulmonary physicians, spread geographically around the country.

Physicians eligible for the two panels would take a course on the relevant disases, and have to pass some sort of test to be included. For radiologists, the B-reader exam might suffice. For pulmonologists, a new exam would be designed to test general knowledge of asbestos-related diseases. This might seem an expensive enterprise, but the total cost would be far less than what is now spent on screening evaluations, re-evaluations, and legal costs for the tens of thousands of claimants.

All chest x-rays would be read in a blinded fashion by radiologists from the panel. The physicians would be paid for each film read, with the money coming equally from both sides out of a common fund. Among the chest x-rays submitted for reading would be a large portion (at least 20%) from patients never exposed to friable asbestos at work, who are otherwise matched to the workers who were exposed (e.g., similar smoking history and age). Inclusion of this group of chest x-rays should help guard against bias in the interpretations. Every chest x-ray would be interpreted on its own merits, and the radiologist would have no way of knowing anything about the person whose film is being read. The radiologist would not know if the subject was ever an asbestos worker, if he was party to any claim, or even if he ever smoked. In this way the radiologist would have no attorney to please or displease with his interpretation, and have only his own integrity to worry about.

In this scheme each chest x-ray would be read by three experienced, unbiased, board-certified radiologists. If at least two of the three radiologists found no asbestos disease on the chest x-ray, that worker would not be allowed to file a claim for asbestos lung disease. Any worker whose claim is rejected in this fashion would be allowed to re-enter the review process after three years.

If two of the three radiologists felt there was some asbestos-related (or silica-related) disease on the screening chest x-ray, the individual's work history would be checked; if in fact he ever worked with or around asbestos, he would then go for a clinical examination, by the pulmonary physician, to evaluate his overall medical condition (including lung function tests).

A final report would be filed by the pulmonary physician. He or she would also be paid from a common fund, and not directly by either side. After the report is filed any dispute (other than about interpretation of the initial chest x-ray) could be litigated. In this manner bogus cases based on over interpretation of chest x-rays would be eliminated.

What are the legal impediments to a medical solution?

The legal solution is far more complex, of course, since it would have to be
a) passed into law by Congress, and
b) accepted in spirit and practice by plaintiff and defense attorneys.

Understandably, the main impdediment is the people who stand to gain the most from mass tort filings, and that's not the claimants. It's the trial attorneys, of course, the group that, with aide of some unethical physicians, helped manufacture the bogus claims. (It is necessary to point out that this is not a diatribe against plaintiff lawyers, per se. They serve a vital function in helping truly aggrieved, truly injured plaintiffs achieve justice. My argument is against plaintiff lawyers who seek to gain from the manufacture of cases when there is no injury, and when the plaintiffs are merely pawns in the scheme hacked out by the attorneys.)

Several years ago, when the above bill was before congress, the Trial Lawyers of America (new name: The American Association for Justice) wrote on its web site:

"With Congress considering legislation that would trap workers and citizens injured by asbestos in an elaborate bureaucracy and set up corporate lawyer-prepared medical criteria that would screen out 60 to 80 percent of potential claimants, it might prove useful to review some quotes from past court decisions that make clear the asbestos manufacturers' misconduct."

This statement confuses facts about past company misconduct with the medical truth about current claims. In fact, if most claims were based on legitimate criteria, many more than "60 to 80 percent" would be screened out. In fact, the current scheme of thousands of claims with their interminable delays, and expert pitted against expert for each contested claim, is far more "elaborate" than any bureaucracy set up to blindly review chest x-rays.

In any case, "corporate lawyer-prepared medical criteria" are not going to be acceptable. Furthermore, corporate lawyers have never set the criteria for diagnosing asbestos-related disease, and it seems unlikely they would do so in any national legislation.

In my opinion, Congress' job would be simplified if the individual members asked themselves two basic questions and then acted on their responses:
1) Do we (the U.S. Congress) wish to compensate people with a possible history of exposure to friable asbestos, irrespective of any medical information about them? In other words, should medical information be simply irrelevant in determining compensation? (This in fact is the philosophical position of plaintiff attorneys, and is one side of the fundamental philosophical rift mentioned earlier.)

If Congress agrees with this position -- if the answer to the question is YES -- then Congress should enact legislation to:

  • remove medical diagnoses and medical testing completely out of the claim process; this removal would eliminate the need for physicians to opine that claimants have asbestos-related disease when the evidence is lacking, or argue about subjective interpretation of chest x-rays. It would also free all worker claimants from the onerous process of multiple medical evaluations.

  • develop a worker-compensation schedule based solely on exposure history; while the exposure history would still be debated among lawyers and employers, complete absence of medical issues would greatly simplify the evaluation process.

    If the answer to the first question is NO, then Congress should consider the second set of questions:

    2) Given that workers with possible exposure to friable asbestos should be compensated based on some medical information (first question), should this information come only from physicians not hired or paid directly by either side? In other words, should a system be developed which guarantees the objectivity and integrity of evaluating physicians?

    If the answer to this second question is YES, then legislation should implement the medical solution outlined above, or some similar fair and unbiased process. If on the other hand the answer is NO, then Congress should abandon any attempt to fix the problem, and accept that the current morass created by attorney-generated, medically-unfounded mass claims will continue ad infinitum.

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    Lawrence Martin, M.D.

    Revised: December 16, 2012