Welcome to Ethics Consult -- an opportunity to discuss, debate (respectfully), and learn together. We select an ethical dilemma from a true, but anonymized, patient care case, and then we provide an expert's 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 in cases of noncompliance.
Do you believe this is a fair policy?
Yes: 25%
No: 75%
And now, bioethicist Jacob M. Appel, MD, JD, weighs in.
The CDC estimates that tobacco smoking costs the U.S. economy more than $300 billion annually, while a in the Journal of Health Economics attributes 21% of the nation's healthcare costs to obesity. Much of this burden falls upon employers through increased insurance premiums and lost worker productivity.
In an effort to avoid such expenditures, businesses and nonprofit organizations have increasingly turned to "tobacco-free" and "healthy-weight" hiring policies. When several large U.S. 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 institutions and nonprofits. A range of entities, from hospitals to fire departments, have since adopted such restrictions and have met little resistance. Citizens Medical Center in Victoria, Texas, now requires all new hires to have body mass indexes under 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 privacy rights of employees.
Arguably, one of the major benefits of modern work life is its inability to reach into the home. Most employees no longer live in "company towns"; their bosses do not track their church attendance or regulate with whom they fraternize. Yet the rise of social media has eroded some of these barriers. In an effort to protect their own images, companies can -- and sometimes do -- fire workers who post offensive statements online. Regulating employee health reflects another way in which public-private barriers are breaking down. In addition to economic concerns, employers may have genuine worries about the public image conveyed by an unhealthy employee, such as a physician or a nurse who posts photographs of herself smoking cigarettes on the internet.
What some well-intentioned individuals view as an attempt to encourage healthy living, critics see as an effort to demonize those who live unhealthy lives. Opponents also express fears that such policies will fall disproportionately upon low-wage workers. In fact, the New York Times that of the first 14 applications turned down for positions at University Medical Center of El Paso under a smoke-free hiring policy, "one was applying to be a nurse and the rest for support positions." After a European Union court ruled in favor of Karsten Kaltoft, a childcare worker who claimed obesity to be a disability, was fired for his weight, a British study revealed that nearly half of 1,000 British employers would not hire overweight applicants, often believing them to be lazy and incompetent. Policies like that proposed by the hospital in this Ethics Consult risk furthering such stereotypes.
These issues have proven among the most divisive in healthcare -- often pitting leading 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-smoking organization, the American Legacy Foundation (ALF), strongly opposes such policies. As the ALF's chief counsel told the New York Times in 2011, "We want to be very supportive of smokers, and the best thing we can do is help them quit, not condition employment on whether they quit. Smokers are not the enemy."
Jacob M. Appel, MD, JD, is director of ethics education in psychiatry 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 a bioethics MA from Albany Medical College.
Check out some of our past Ethics Consult cases: