Textbook of Maritime Medicine

The 1997 ILO and WHO (World Health Organization) guidelines concerning the conduct of pre sea and periodic fitness medical examination for seafarers establish an indicative list of pathological conditions that can lead to fitness restrictions with respect to periods of time, the duty, the geographic sector of operation, the type of ship, the medical assistance available, or make the seafarer temporarily or permanently unfit. These lists should be used as a guide, but can not replace a sensible medical judgement. The maritime medicine physician in charge of the assessment of the fitness of seafarers enjoys some liberty to make his decision.  This liberty is used mostly for the active seafarer for whom he will adhere closely to the relevant national guidelines. A decision of unfitness nearly always indicates the end of a maritime career, and may represent a source of conflict.

The ILO conventions C 73 (1946) on medical examination of the seafarers, C 113 (1959) on medical examination of the fishermen, and the 2006 maritime labour convention (ILO) underline that any seafarer that has been denied a fitness certificate, or granted a certificate with limitation in terms of time, field of work, or trading area shall have the opportunity of  a further medical examination by another practitioner, or by a medical referee who is fully independent of ship owners and trade organizations.

The contestation of a decision of unfitness is the most common conflicting situation in which the maritime physician can be involved. Normally, the possibility of a second medical opinion by a specialist, or a presentation of the case to an expert panel, will solve the problem. The procedures to obtain a second opinion may differ from one country to another, but remain under the guarantee of the ILO maritime labour convention of 2006. Most countries with an anglo-saxon cultural background rely on a second medical expert's advice ant then turn to a medical commission in case of a persistent disagreement, whereas other countries rather present the case directly to a medical panel.  The qualified physician who issues a certificate of unfitness, or with limitations, must inform the applicant, explain the reasons for the decision and give information on appeal procedures. The applicant must confirm that he has received and understood the information by signing the document

Obviously, it is most important that the initial application medical form is duly completed and that it includes all relevant medical evidence necessary to make a sound decision. Exchange of information among practioners would improve the process. A national register with records from all examinations and accessible for all physicians would be even better, provided the obligation of confidentiality is guaranteed. A system of this kind would secure certain homogeneity in the evaluation process and possibly prevent different physicians to make conflicting decisions.

The situation in France differs somewhat from the 1997 ILO and WHO guidelines, as well as from he C 73 convention. The medical commission deciding in cases of conflict is composed of some maritime physicians and one counselling practitioner from the social security establishment for seafarers (ENIM). These commission members have good knowledge of the maritime industry, but are completely independent of ship owners’ organizations and seafarer unions. However, to find medical expert who in every way are independent to any organization belonging to the maritime industry is difficult because matters concerning aptitude for service at sea, examination of medical conditions that are not compatible with work at sea, require good knowledge of the working conditions and thus a fair acquaintance of the maritime industry.. However, it is imperative that the situation of any seafarer, when appealing against a decision that went against him, is treated with objectivity and that his rights are protected.

The maritime medicine physician on board or at shore is committed to the ethics of medical practise: serve the individual with total respect of confidentiality and freedom of acting including the freedom to choose his own practitioner. The latter may be difficult when we consider the situation on board a ship, and when seeking medical advice from a telemedical service. This situation must be acknowledged and accepted by the physicians and by the seafarer in order to prevent the potential conflicting situations that may evolve.

The maritime physicians also act as occupational physicians in the maritime industry and hence become counsellors to the ship owners. They must follow the law and the flag regulations in medical matters, and may also take action in matters of security, particularly in questions regarding the role of the human element. The abuse of alcohol, narcotics and medicines plays an important part in this setting.

There are different approaches to the question of drug and alcohol abuse: In the USA systematic control systems were introduced in the eighties, prescribed by law. Controls are performed by personnel often without medical competence or training. In Europe there is no specific legislation to govern the question of drug and alcohol abuse. Hence, the question of individual liberty will sometimes get into conflict with the concern for collective safety. Here, physicians may have to involve themselves in drug testing and consequently find themselves trapped between obligation for confidentiality and obligation to report events that are potentially threatening to safety. Because the obligation for confidentiality is absolute and their loyalty is divided, the situation can in some instances only be solved by declaring the seafarer unfit without releasing any medical information.

A situation of this kind will not occur under the American system since their drug testing is made routinely upon recruitment, after every injury, accident or disease, and even randomly. Physicians are not involved in these testing processes which increasingly rely on breath analyzers and saliva tests. The testing are carried out by dedicated employees, or by personals outside of the company. The biological material is analyzed in certified laboratories, if necessary. The employer is informed directly of the results and will take the appropriate measures. It has to be noticed that lately the general attitude has changed from a systematic repressive and disciplinary on to an orientation towards medical care for the employees who test positive.

The lack of a clear and uniform regulation at a European level may place the maritime physicians in an ambiguous position between medical ethics not founded on legislation on one side, and by a situation with voluntary drug and alcohol testing and the responsibility for collective and individual safety on the other. The latter also implies his duties as an occupational physician.

European countries lag 10 to 15 years behind the USA in this matter. Only a generally accepted legislation making drug and alcohol testing mandatory will relieve the maritime physicians from this potentially conflicting situation.