Workplace

April 2013

Professional

The pre-employment medical

Ethical dilemmas for GPs

Volume 42, No.4, April 2013 Pages 249-251

Chandramani Thuraisingham

Sivalingam Nalliah

Background

In many workplaces, employment is conditional on a successful pre-employment medical examination. This examination is usually conducted by a general practitioner on the employers’ panel of approved clinics or by an in-house company doctor.

Objective/s

This article uses a case study to illustrate some of the ethical dilemmas that may be faced by GPs in the course of performing a pre-employment medical examination.

Discussion

Ethical issues discussed in this article include: Is it ethical for employers (based on physicians’ reports) to select workers based on ‘absence of illness’ rather than ‘fitness for work’? Should physicians divulge the illness of potential workers to third parties? What are the boundaries of a clinician’s duty of care in the pre-employment medical examination setting?

Case study

A woman, 34 years of age, presented to an in-house company doctor for a pre-employment medical examination before accepting a position as an administrative executive. She was thin, appeared comfortable and alert, but had a ‘staring’ look. Her pulse was 125 bpm, regular in rhythm; blood pressure 110/80 mm Hg. She had detectable proptosis with eyelid retraction but lid lag was not elicited. Her thyroid was not palpable. She denied weight loss but was troubled by palpitations and anxiety, which she ascribed to work stress, and had led to her resignation from two previous positions for a ‘change of environment’.

The company required only standard blood tests and a chest radiograph as part of the examination. Suspecting hyperthyroidism, the examining physician, after obtaining informed consent, added thyroid function tests and an electrocardiogram.

Hyperthyroidism was confirmed by:

  • elevated levels of free T4–51.0 pmol/L (normal range 9.0–25.0 pmol/L)
  • free T3–15.8 pmol/L (normal range 3.5–6.5 pmol/L)
  • low thyroid stimulating hormome levels of 0.01 mIU/L (normal range 0.4–4.7 mIU/L).

An electrocardiogram showed sinus tachycardia.

Treatment for thyrotoxicosis was initiated immediately and she was certified fit for her new position. With her consent, the doctor informed the company that she had an incidental non-life threatening medical condition that would require regular monitoring and treatment until stabilised, the details of which were not divulged as she had not consented to the provision of this information to her employer. She accepted the position and reported for work on the due date, 6 weeks later.

The doctor’s decision was questioned by the employer 6 months later because, even though under the company’s medical policy employees received medical benefits regardless of whether they were work related or not (with the usual exclusions, eg. dental procedures and cosmetic surgery), the company had incurred recurring medical expenses throughout her term of employment. The company was also wary about the possibility of increased sickness absence in the future.

In many workplaces, employment is conditional on a successful pre-employment medical examination (PEME), driven more by traditional practices rather than by evidence.1 Employers can often choose to revoke an offer of employment if the potential employee refuses to undergo a PEME. However, in some countries, disabled employees are excluded from a PEME under the Medical Disabilities Act.2 In public service occupations, such as the armed forces, police force, and fire services, a PEME is mandatory, as these jobs are not only high risk, but unfitness of an employee may also place others at risk.

The PEME is usually conducted by a general practitioner on the employers’ panel of approved clinics, or by an in-house company doctor, after obtaining the employee’s consent. However, employers commonly do not provide the examining GP with the employee’s position description, therefore the GP is unable to relate the PEME to the position’s tasks and the interpretation of ‘fitness’ or ‘unfitness’ is left solely to their discretion.3

Ethical dilemmas

The Case study highlights three ethical issues that may arise during a PEME:

  • Is it ethical for employers to use physicians’ reports to select workers based on ‘absence of illness’ rather than ‘fitness for work’?
  • Should physicians divulge the illness of potential workers to third parties?
  • What are the boundaries of a clinician’s duty of care in the PEME setting?

Should ‘absence of illness’ mean ‘fitness for work’?

Employees should not be discriminated against unlawfully for purposes of employment because of an illness. Instead, employers should consider the individual characteristics of each applicant in the light of the inherent requirements of the job.4

The goal of a PEME is to determine whether an individual is fit to perform his or her job without risk to himself or others. This is more justified when the job involves working in hazardous environments, requires high standards of fitness, is required by law, or, when the safety of other workers or the public is at risk.1

Unfortunately, some employers may misconstrue the scope of a PEME and use it as a management tool, so that only those without illness are employed.

While GPs may be the legitimate health professionals to detect a medical condition in a potential employee at a PEME, they may not be familiar with the occupational risks inherent in some jobs.5 Occupational safety and health physicians are trained to balance the physical and mental demands of job tasks with the health status of employees and, as such, may be better placed to perform these types of examinations.

Is the selection of workers on health grounds to reduce sickness absence an ethical practice for healthcare professionals to be involved in, or is it an abuse of their privileged position in society?

To divulge or not to divulge?

Contractual appointments of panel doctors often stipulate certain conditions regarding provision of patient-sensitive information.6 For example, it is common practice in most companies in Malaysia to obtain written consent from new employees authorising the doctor to provide the PEME findings to the company’s recruiting officer. Under these circumstances, the examining doctor is no longer obligated to maintain confidentiality.3

In the Case study, no such consent was obtained before the examination. Additionally, the employee had personally covered the cost of the extra investigations and treatment.

Duty of care

In the Case study, the ‘examining doctor’6 was bound by a contractual obligation to the company to conduct a standard PEME at the in-house company clinic, requiring not more than basic blood tests and a chest radiograph. The employee told the doctor that she had no regular doctor, and having suspected hyperthyroidism the doctor went beyond the limits of the company’s requirements and ordered thyroid function tests (TFTs) and an electrocardiogram, after obtaining informed consent and an agreement from the patient that she would bear the associated costs.

As the employee did not have a regular doctor, sufficient proximity was established to create a patient-doctor relationship in the PEME. The examining doctor recognised that the reported ‘anxiety’ was likely an inherent part of her disease state. In the treating doctor’s view, her medical condition would not prevent her carrying out the tasks required in the job, so he did not deem her ‘temporarily unfit’.3 He determined that her hyperthyroidism required immediate treatment and felt competent to initiate this. The doctor also expected a significant response to treatment by the employment commencement date (6 weeks away). His paramount concern was the patient’s long term health, and he was guided by the customary rules of his profession.

The wider responsibility of the doctor to his patient was disregarded by the company in its narrow scope of the PEME. The company was unaware of the employee’s exact diagnosis as she did not consent to divulge this information.

Another doctor in this situation may have certified her fit, but not seen the need to carry out any more tests in the absence of an established patient-doctor relationship, and instead, referred the patient on.

A doctor hired under a contract of service may deem his duty of loyalty to the company as more important than the patient-doctor relationship.

At what point does the doctor’s obligation become ‘supraobligatory’, to go beyond what is reasonably expected of the average GP?7

Discussion

Pre-employment medical assessments were originally intended to reduce risks to the health and safety of workers in hazardous workplaces, as well as to prevent spread of communicable disease. They were designed to help ‘match’ workers to jobs they were capable of doing, safely and without undue risk to others. Today however, there is a risk that employers will turn the PEME into a screening process to select relatively ‘healthy’ workers in an attempt to minimise sickness absence and control costs.

Physicians are bound by professional standards of care to recommend treatment for their patients’ wellbeing. They must balance competing loyalties between the patient and employer, as well as their own professional standards and moral convictions.

The Case study demonstrates that ethical issues in clinical practice often have to be dealt with pragmatically, case-by-case, and not theoretically.8 Employers today may attempt to set the standards of care and physicians need to be wary of this.

Clear guidelines for the scope of work of GPs conducting PEMEs should be formulated. Doctors should be objective in their assessments, and their role should not be perceived as a way of excluding applicants with existing illness from employment.9

Competing interests: None.
Provenance and peer review: Not commissioned; externally peer reviewed.

References

  1. Pachman J. Evidence base for pre-employment medical screening. Bull World Health Organ 2009;87:529–34.
  2. Equality Act 2010. Available at www.legislation.gov.uk [Accessed 28 January 2013].
  3. Guideline for conducting pre-employment medical examination. Available at www.soem-mma.org [Accessed 28 January 2013].
  4. Hely B. Human Rights: ‘Judge me by what I can do – not by what you think I can’t’. Pre-employment medical assessments. Law Society Journal December 2006, page 48. Available at http://humanrights.gov.au/legal/publications/law_society_journals/2006/preemployment_medical_assessments.html [Accessed 28 January 2013].
  5. Lin K. Pre-employment examinations for preventing occupational injury and disease. Am Fam Physician 2011;83:1270–1.
  6. The Malaysian Medical Association. Codes of medical ethics. [Online]. Available at www.mma.org.my [Accessed 28 January 2013].
  7. Whitaker S. Health examinations on new employment: ethical issues. In: Westerholm P, Nilstun T, Ovretveit J, editors. Practical ethics in occupational health. Oxon, United Kingdom: Radcliff Medical Press, 2004;91–102.
  8. Christie RJ, Freer C, Hoffmaster CB, Stewart MA. Ethical decision making by British general practitioners. J Royal Coll Gen Pract 1989;39:448–51.
  9. Local Government Employers. Pre-employment medical assessments. [Online]. Available at www.lge.gov.uk [Accessed 28 January 2013].

Correspondence afp@racgp.org.au

05 April 2013 06:27

Re: The pre-employment medical

Davendralingam Sinniah

Professor

International medical University Kuala Lumpur

Patient confidentiality takes precedence over employer’s interest
Davendralingam Sinniah
I refer to the interesting article by Thuraisingham and Nalliah (1) based on a potential employee (PEE) seen by a company doctor for a pre-employment medical examination (PEME). Examination reveals clinical signs leading to tests confirming hyperthyroidism. The doctor takes PEE as a patient, starts treatment, and certifies her employable. With PEE’s consent the doctor makes partial disclosure to the employer that she has a non-life threatening illness that requires treatment until stabilised. Six months later, the company questions the doctor’s decision that declared PEE fit for employment as this has incurred recurring medical expenses for her management.
The authors highlight 3 ethical dilemmas that may arise during a PEME:
1. Is it ethical for employers to use physicians’ reports to select workers based on ‘absence of illness’ rather than fitness to work?
2. Should physicians divulge the illness of potential employees to third parties?
3. What are the boundaries of a clinician’s duty of care in the PEME setting?
In answer to Questions 1 and 2, the American Medical Association’s opinion is where a physician’s services are limited to performing an isolated assessment of an individual’s health or disability for an employer, the information obtained by the physician as a result of such examinations is confidential and should not be communicated to a third party without the individual’s prior written consent, unless required by law. If the individual authorized the release of medical information to an employer or a potential employer, the physician should release only that information which is reasonably relevant to the employer’s decision regarding that individual’s ability to perform the work required by the job (3). However, the potential employer could provide a written guideline to the PEE ahead of time that clearly details the PEME and tests required as a pre-condition of employment. This form should include a paragraph to be signed by the PEE giving consent to the doctor to disclose all his findings to the company. The doctor should satisfy himself that PEE has sufficient information about the scope, purpose, and likely consequences of the examination disclosure, and understands that the relevant information cannot be concealed from the potential employer (4). The doctor should also offer to show PEE or provide her a copy of the report to be forwarded to the employer.
With respect to question 3, the guidelines of the Malaysian Medical Association Code of Medical Ethics states that when a company doctor finds on examination that an employee is unfit to work, he shall advise the employee to consult his own doctor or may, in an emergency, send him direct to hospital (2). Likewise, in the PEME scenario, the doctor should inform PEE that his examination suggests hyperthyroidism that requires the attention of her doctor. He should not invite or influence PEE to become his patient. He should offer to refer PEE to a hospital should she not have her own doctor. The patient however has autonomy to choose or change her doctor at any time.
In providing only partial information about PE’s examination to the employer, the doctor respected patient confidentiality. Annoyance of the employer over lack of full disclosure should be managed by educating the employer on medical ethics, confidentiality, and professionalism. Should the company desire more detailed disclosures on PEs, it should provide written guidelines to the PEs ahead of time, clearly detailing the PEME and tests required, and written consent of the PE to disclosure of the required information by the doctor to the employer. This would absolve the doctor from seeking further consent for disclosure.
References
1. Chandramani Thuraisingham and Sivalingam Nalliah Volume 42, No.4, April 2013 Pages 249-251
2. Malaysian medical Association Codes of Medical Ethics (Online). Available at www.mma.org.my (accessed 5 April 2013).
3. Opinion 5.09 - Confidentiality: Industry-Employed Physicians and Independent Medical Examiners - Issued July 1983; Updated June 1994; updated June 1996; updated December 1999 based on the report "Patient-Physician Relationship in the Context of Work-Related and Independent Medical Examinations," adopted June 1999. http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/opinion509.page? (accessed on 5 April 2013).
4. Medical Ethics Today: The BMA’s Handbook of Ethics and Law. BMA Ethics Department. BMJ Books, Wiley-Blackwell, third edition, 2012. Chapter 5: Confidentiality. Page 183 -228. Employment, insurance and other affairs, page 217 -8.

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