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Apr 15, 2013

As more employers consider how to reduce the percentage of tobacco users in their workforces, one policy in particular has raised eyebrows and hackles more than others: No-hire tobacco policies.

Today, it’s mostly health care systems implementing these policies barring the hiring of tobacco users. They easily argue the importance of employing a workforce that boldly and uniformly stands for healthy lifestyle habits.

On the surface, it’s hard not to agree with the policy. And since health workers are the least healthy among us, perhaps we should consider this a laudable stand by their employers. But once you burrow into the ethical considerations, you may discover what a complex, divisive issue this is.

Policies that recognize the messiness of addiction

For example, should a health care system shun people with health risks or does doing so make a patient using tobacco feel less comfortable seeking its medical advice? Do these policies recognize addiction and its messiness?

Most tobacco users endure multiple quit attempts before they’re successful — if they’re successful. If a health care system doesn’t support these attempts among its employees, what message does that send patients? And what of the social determinants of health that lead to a number of unhealthy lifestyle behaviors, including tobacco use? Do these policies, in essence, isolate and discriminate against individuals born into the wrong zip code?

Two articles currently appear on the New England Journal of Medicine’s website. One is the ethics of not hiring smokers. The other is conflicts and compromises in not hiring smokers.

We’re not isolated any more

Both tackle these questions at length and suggest any employer start elsewhere in its effort to curb tobacco use. The latter article raises an additional controversial question. It contends that the days when you can consider your behavior in isolation are soon to be behind us.

Similarly, policies against hiring smokers shift the debate from the question of where one smokes to that of whether one smokes. Are these policies aimed at tobacco, which is harmful and destructive, or at people who are addicted to tobacco, who may be seen as victims? Do the policies target legally available products or people who make a personal choice that contributes to a social burden and could conceivably choose otherwise? Are the rules designed to reduce smoking, which is a population health goal, or to fence out smokers, which may be an institutional financial goal? How, exactly, should we look at these policies?

We believe we should see them as one product of a growing recognition that changing behaviors is hard, that combating addiction is harder, and that behaviors that were once seen as exclusively private often have profound societal effects. As a result, many stakeholders are trying to change unhealthy behaviors through mechanisms as varied as legislative requirements for calorie labeling in some restaurants, bans on the sale of large servings of sugar-sweetened beverages, and Affordable Care Act provisions allowing employers to provide rewards or penalties worth up to 50 percent of employees’ health insurance premiums on the basis of health assessments, including smoking status. Those policies would have seemed like hard paternalism back when no one questioned passengers’ right to smoke on airplanes, but they might be seen as considerably softer now in light of social trends, and perhaps in the future we won’t consider them paternalistic at all.”

Keeping an eye on the balance

As we’re seeing with outcomes-based wellness, I suspect these authors are correct. Ultimately, our view of what’s paternalistic will change. In the past, paternalistic meant providing jobs for life and pension plans.

Right now, paternalistic means “Big Brother” to many. Tomorrow, paternalism will involve looking out for our social good, as these authors suggest.

The trick, as we shift toward this last definition of paternalism, is keeping an eye on the balance between policies and programs that make health widely and almost innately practiced, and those that leave people to fend for themselves.

This was originally published on Fran Melmed’s free-range communication blog.

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