A hospital in Texas recently made the national news when it announced that it would no longer hire obese workers. According to the new employment policy at the Citizens Medical Center in Victoria, Texas, all new employees — be they physicians, nurses, orderlies or janitors — must have a body mass index (BMI) of less than 35.
For a man who is 5’ 10” tall (the average for American men), this would mean they must weigh no more than 245 pounds. The average American woman, who tops out at 5’ 4”, would need to tip the scales at 204 pounds or less. Of course, BMI is only a proxy for body fat based on an individual’s height and weight. An extremely muscular man or woman, for example, might have a body mass index that puts them in the obese category even though they are far from fat. Similarly, a low body mass index doesn’t necessarily mean that a person is healthy; those with BMI’s under 18.5 are dangerously underweight. I don’t know whether the hospital’s policy makes allowances for gym rats or those with eating disorders.
When I first heard about this case, I thought that maybe the hospital was concerned about the ability of obese workers to do their jobs safely and effectively. Nurses and orderlies in particular are often called upon to assist patients in getting into and out of bed, or to wheel gurneys or other heavy pieces of equipment though the hallways. Numerous studies have shown that work-related injuries are both more common and more costly among the obese.
Alternatively, I reasoned, maybe the hospital is concerned about burgeoning insurance costs. According to a study by the US Centers for Disease Control, we spend over $150 billion a year to treat obesity and its related diseases. Employers pick of the bulk of these costs through workplace-provided insurance. Faced with ever increasing insurance premiums, many firms are now requiring employees who are overweight or who smoke to pay a greater percentage of the cost. Refusing to hire overweight workers might simply be the next step in reining in health insurance costs.
It turns out, however, that concerns about worker safety or insurance costs have nothing to do with the new hiring policy. Rather, according to hospital officials, the rationale for this weight restriction is professional image. Apparently, most patients at the hospital expect staff to be professional in both their appearance and their demeanor. This means that they expect their nurses, doctors and even the woman who cleans the bed pans to look healthy. It may even, in the words of one administrator, encourage patients to change their own unhealthy lifestyle.
This is where Citizen Medical Center gets it wrong. Most people are unlikely to live a more healthy lifestyle simply because they have skinny nurses, svelte co-workers, or sinewy friends. If that were the case, we’d all be thin and beautiful seeing as we are continuously bombarded with images of blonde supermodels and tattooed soccer stars selling products like underwear, cars, and fast food smoothies. Instead, people are more likely to change their lifestyle if they are inspired by others. If the goal of the hospital’s policy is to encourage their patients to live more healthy and active lives, they’d be better off if they offered incentives to their current employees to lose weight — nutrition support groups, gym memberships, and bonuses or other rewards for those who achieve and maintain a health weight.
Not only would such an approach inspire patients and improve employee morale, but it would avoid the prickly ethical and legal concerns raised the hospital’s new hiring policy. For example, Texas employment law does not explicitly prohibit weight discrimination, only discrimination based on race, age or religion. Similarly, the US Equal Employment Opportunity Commission has ruled that these types of hiring restrictions — refusing to hire workers on the basis of weight or physical appearance — are not discrimination per se. However, the Americans with Disability Act does prohibit discrimination against those with physical impairments.
While weight within a certain range is not considered a physical impairment under the ADA, morbid obesity (defined as having a BMI of 40 or more) is a physical impairment. As one Texas attorney described it: “We have this weird situation where you can be discriminated against if you’re fat, but not if you’re morbidly obese.” So, Citizen Medical Center might successfully defend themselves if sued by a rejected employee who had a BMI of 36, but could lose if sued by someone with a BMI of 42.
I’m in favor of creating a workplace environment that encourages employees to make healthy lifestyle changes, such as offering insurance rebates to those who exercise regularly or who don’t smoke. I believe that hospitals like Citizen Medical Center should serve as models for healthy living — for their employees, their patients and their community. However, they need to do so in a way that is helpful and supportive. They need to provide their staff with opportunities for improvement, rather than promulgate a misguided and potentially discriminatory policy that will accomplish nothing.
A public health researcher and ethicist by training, Dr. Sean Philpott is a professor of bioethics at Union Graduate College in Schenectady, New York. He is also the Chair of the US Environmental Protection Agency’s Human Studies Review Board, which reviews all research involving human participants submitted to the EPA for regulatory purposes.
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