Ethics consultation: frequent forced weighings for hospital workers? MD/JD weighs

Welcome to Ethics Consult – an opportunity to discuss, (respectfully) debate and learn together. We select an ethical dilemma from a real, but anonymized, patient care case, then provide expert commentary.

Last week, you voted on whether it’s fair for a hospital to conduct employee health assessments related to smoking and body weight, with the possibility of dismissal for non-compliance.

Do you believe this is a fair policy?

Yes: 25%

Nope: 75%

And now, bioethicist Jacob M. Appel, MD, JD, steps in.

The CDC estimates that smoking costs the US economy more than $300 billion a year, while a 2012 study in the Journal of Health Economics attributes 21% of the nation’s healthcare spending to obesity. Much of this burden falls on employers due to increased insurance premiums and lost worker productivity.

To avoid such expenses, businesses and nonprofits are increasingly turning to “no tobacco” and “healthy weight” hiring policies. When several major US corporations – including Alaska Airlines – stopped hiring smokers in the 1980s, a backlash led 29 states to pass right-to-work laws for tobacco users, although many included exceptions for healthcare facilities and non-profit organizations. A range of entities, from hospitals to fire departments, have since adopted such restrictions and met little resistance. Citizens Medical Center in Victoria, Texas now requires all new hires to have a body mass index below 35 (normal weight is a BMI of 18.5 to 25). These policies raise fundamental questions about the balance between the prerogatives of employers and the right to privacy of employees.

Arguably, one of the major perks of modern working life is its inability to access home. Most employees no longer live in “company towns”; their bosses don’t track their church attendance or regulate who they fellowship with. Yet the rise of social media has eroded some of these barriers. In an effort to protect their own image, companies can — and sometimes do — fire workers who post offensive statements online. Regulating employee health reflects another way in which public-private barriers are falling. In addition to economic concerns, employers may have real concerns about the public image conveyed by an employee in poor health, such as a doctor or nurse who posts photos of themselves smoking cigarettes on the Internet. .

What some well-meaning people see as an attempt to encourage healthy living, critics see as an effort to demonize those who lead unhealthy lives. Opponents also worry that such policies will disproportionately affect low-wage workers. In fact, the New York Times reported that of the first 14 applications turned down for positions at El Paso University Medical Center under a smoke-free hiring policy, “one was applying to be a nurse and the others for support positions.” After a European Union court ruled in favor of Karsten Kaltoft, a childcare worker who claimed obesity was a disability, was fired for his weight, a UK study has found nearly half of 1,000 UK employers would not hire overweight candidates, often believing them to be lazy and incompetent. Policies such as the one proposed by the hospital in this ethics consultation risk fostering such stereotypes.

These issues have proven to be some of the most divisive in health care, often pitting major advocacy groups against each other. For example, the American Lung Association and the American Cancer Society refuse to hire smokers; in contrast, another major anti-tobacco organization, the American Legacy Foundation (ALF), strongly opposes such policies. As the chief lawyer of the ALF told the New York Times in 2011, “We want to be very smoker-friendly, and the best thing we can do is help them quit, not make employment conditional on them quitting. Smokers are not the enemy.”

Jacob M. Appel, MD, JD, is director of psychiatric ethics education and a member of the institutional review board at the Icahn School of Medicine at Mount Sinai in New York City. He holds an MD from Columbia University, a JD from Harvard Law School, and an MS in Bioethics from Albany Medical College.

Check out some of our previous ethical consultation cases:

Who decides if the child is “dead?”

Authorize the mixed hospital room?

Let the patient pray for the pneumonia to go away?

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