Using this handbook
The information and recommendations given in this handbook are designed to be fully compatible with the ILO/IMO Guidelines on Seafarer Medical Examinations. They should be used as a supplement to these guidelines or to any national equivalents. For the latter it is essential to check that the national equivalent does not contain additional requirements not covered in the international guidelines.
Access to relevant clinical information
Both the international guidelines and this handbook assume that the seafarer will be aware of the nature of any medical condition they have had, that they will disclose this information and that it is possible to contact other clinicians who have treated them to obtain further information. Where this is not possible it may be appropriate to perform additional clinical tests as part of the medical examination. These may be done as a requirement of a national authority, an employer/ship operator or an insurer. Examining doctors may themselves also identify needs for additional investigations, either because information is lacking or because they have reason to believe that the seafarer may have a relevant condition that has not been fully evaluated.
Where additional tests are used to assess compliance with the fitness criteria in the ILO/IMO Guidelines it is important to take a view on their validity and to be aware of the risks of false positive or false negative results. Unless a test has a very high level of validity it will not usually be appropriate to base a fitness decision solely on a single result.
It will sometimes be essential to wait for further clinical reports or test results before taking a decision on fitness. Seafarers and others who use the results of medical examinations need to be made aware of this.
Additional fitness criteria imposed by employer/ship operator or insurer
Some employers and others with an economic interest in reducing the costs of illness in seafarers require compliance with fitness criteria over and above those in the ILO/IMO Guidelines. These are not covered in this handbook and advice needs to be obtained from those who impose them.
Examining doctors need to consider the ethical and discriminatory aspects of compliance with such fitness criteria before agreeing to use them. This is because they lack to political consensus that underlies the ILO/IMO Guidelines and most national statutory standards. In addition they serve the economic interests of one group and this can be at the expense of access to employment at sea. National statutory standards that comply with the relevant international conventions should represent a political decision on the balance between risk and discrimination.
Conditions not covered by this handbook
A large number of medical conditions not discussed in this handbook and where decision taking is simpler are listed in the ILO/IMO Guidelines. These should be followed when appropriate.
There are an even larger number of conditions that are less common and are not specifically covered in either Guidelines or Handbook. A sound approach to clinical decision taking that is based on the principles listed in STCW 2012, section A-1/9 is needed here:
- "Parties, when establishing standards of medical fitness for seafarers as required by regulation I/9, shall adhere to the minimum in-service eyesight standards set out in table A-I/9 and take into account the criteria for physical and medical fitness set out in paragraph 2. They should also take into account the guidance given in section B-I/9 of this Code and table B-I/9 regarding assessment of minimum physical abilities. These standards may, to the extent determined by the Party without prejudice to the safety of the seafarers or the ship, differentiate between those persons seeking to start a career at sea and those seafarers already serving at sea and between different functions on board, bearing in mind the different duties of seafarers. They shall also take into account any impairment or disease that will limit the ability of the seafarer to effectively perform his/her duties during the validity period of the medical certificate.
- The standards of physical and medical fitness established by the Party shall ensure that seafarers satisfy the following criteria:
- have the physical capability, taking into account paragraph 5 below, to fulfil all the requirements of the basic training as required by section A-VI/1, paragraph 2;
- demonstrate adequate hearing and speech to communicate effectively and detect any audible alarms;
- have no medical condition, disorder or impairment that will prevent the effective and safe conduct of their routine and emergency duties on board during the validity period of the medical certificate;
- are not suffering from any medical condition likely to be aggravated by service at sea or to render the seafarer unfit for such service or to endanger the health and safety of other persons on board; and
- are not taking any medication that has side effects that will impair judgement, balance, or any other requirements for effective and safe performance of routine and emergency duties on board."
- "Parties, when establishing standards of medical fitness for seafarers as required by regulation I/9, shall adhere to the minimum in-service eyesight standards set out in table A-I/9 and take into account the criteria for physical and medical fitness set out in paragraph 2. They should also take into account the guidance given in section B-I/9 of this Code and table B-I/9 regarding assessment of minimum physical abilities. These standards may, to the extent determined by the Party without prejudice to the safety of the seafarers or the ship, differentiate between those persons seeking to start a career at sea and those seafarers already serving at sea and between different functions on board, bearing in mind the different duties of seafarers. They shall also take into account any impairment or disease that will limit the ability of the seafarer to effectively perform his/her duties during the validity period of the medical certificate.
It may often be possible to take decision on conditions that are not listed by analogy with listed conditions. An example would be to look at the criteria for sudden incapacitation risks used for seizures, cardiac events or the use of insulin as benchmarks for any other condition where there was a similar risk. Where the risk is of recurrence of a condition that may occasionally require urgent hospitalisation the criteria for say renal stones or hernia may be relevant. In a few situations there may be standards used in related areas such as the military that can be adapted.
Where clinical reports are obtained to help with decision-taking on conditions without specific criteria it is important to recognise that information about the probability of recurrence, progression or fluctuation in severity of a condition may be needed. It is the level of work related impairment that can be expected, either constantly if the condition is stable or when it worsens if it is variable, that is critical to a decision on fitness. These are not the usual concerns of clinicians who are likely to be focused on treatment. Hence the examining doctor requesting a report should specify that this is the sort of information needed to enable a sound decision to be made.