Student Award in Clinical Ethics: 2021 Winning Essay Explores Potentially Thorny Issue
ASCO and its Ethics Educators Special Interest Group are pleased to announce Tam Tran, OD, as the winner of the 2021 Student Award in Clinical Ethics. Dr. Tran graduated this year from Illinois College of Optometry and plans to make binocular vision a focus of his career. His winning essay, “The Ethical Muddle of Sick Notes: Can We Do Better?” appears below.
The Student Award in Clinical Ethics competition, sponsored by Alcon, is open to optometry students during any point in their professional program at an ASCO-affiliated school or college of optometry. The winner receives an engraved plaque and $1,000.
ASCO thanks all students who submitted essays this year.
The Ethical Muddle of Sick Notes: Can We Do Better?
By Tam Tran, OD
To utilize the benefit of paid leave or be absent from school for a health reason, employees and students are often required to present a “sick note” from a doctor. It is not uncommon for patients to ask their optometrists to provide such a note. Many requests for sick notes are clinically legitimate, but they can be misused, too. For example, patients could withhold information to prolong diagnosis or treatment. In many cases, the issue is not a perplexing medical decision, but rather an immoderate demand. Thereby, optometrists can find themselves in a quandary: grant the request for a note to “proactively serve the needs of the patient,” as stated in the American Optometric Association (AOA) Standards of Professional Conduct,1 or deny the request based on clinical judgment? Furthermore, should doctors alone carry the responsibility of deciding whether a patient should stay home or return to work or school?
JM, a 52-year-old law enforcement officer, presented for severe dry eye OU. He reported eye irritation, photophobia, foreign body sensation, tearing and blurry vision. His best-corrected visual acuity was 20/30 OU. Slit lamp examination showed 3+ superficial punctate keratitis (SPK) OU. JM was counseled to use preservative-free artificial tears, omega-3 fatty acid supplements and warm compresses. He asked for and received a sick note due to being sensitive to light, which prohibited him from driving on duty.
During the follow-up visit one week later, JM said he had been complying with the treatment recommendations, but his condition was unchanged. Tobramycin/dexamethasone eye drops (Tobradex) were added to the treatment regimen. JM requested and received another sick note for sick leave.
During the second-week follow-up appointment, JM reported an improvement in his eye condition, but said he was still experiencing mild-to-moderate discomfort and photophobia. He was advised to use supportive therapies such as sunglasses and artificial tears for symptom relief while on duty. JM said he felt unsafe to drive and persisted in asking for another sick note, which was provided.
During the third-week follow-up, JM’s condition was further improved. Slit lamp examination showed 1-2+ SPK OU and his best-corrected visual acuity was 20/20-2 OU. The attending optometrist cleared him for work. JM, however, insisted that he felt unsafe to drive and wanted another sick note.
At this point, JM had taken three weeks off from work on sick leave. Based on clinical examination, his eye condition had improved enough to allow him to resume working. Yet, he still felt unsafe to drive on duty. As previously noted, optometrists have a duty to proactively serve the needs of their patients; however, they also have an obligation “to conduct themselves with integrity.”1 This requires us to walk a fine line between advocating for patients’ best interests and being truthful in sick notes for patients’ work or school. Was JM’s unease caused by an unknown ailment, or was he taking advantage of his employer’s sick leave policy? Given that no further eye abnormality was observed, additional examination or referral might have only put an unnecessary financial burden on the patient. On the other hand, blatantly accusing him of sick leave abuse would be premature and damaging to the optometrist-patient relationship. With no evidence either way, is it ethical to continue granting JM sick notes as he continues to report eye discomfort?
The ethics argument hinges on the choice between giving patients what they want or offering what they and society need. To tackle this dilemma, we need to uncover its root cause. It has become standard practice for society to demand medical documentation for sick leave. In regard to vision problems, optometrists have become an authority for providing such documentation, for example, on school forms and sick notes. However, because we also have an ethical obligation to act in the best interest of patients, we are put in the odd position of impartial arbiters between patients and their work or school. So far, except for driving restrictions and legal blindness, which are governed by laws, deciding for society who is “worthy” of what vision-related excuses is solely at optometrists’ discretion. Such a situation is destined for trouble.
In fact, this demand for optometrists to “certify” everything eye-related has created a huge burden on both optometrists and patients. As defined in the AOA’s Code of Ethics, it shall be the duty of all optometrists “to conduct themselves as exemplary citizens and professionals with honesty, integrity, fairness, kindness, and compassion,”2 so whatever we write in the note is deemed truthful and accurate by the public. But what if we are not given the whole story? It swings the door wide open for sick leave abuse. As to patients, the policy of mandatory doctor’s notes for sick days adds little to patients’ well-being. They should make their own decisions on whether and when their illness requires medical attention. Unfortunately, the fear of losing jobs forces patients to either continue working instead of resting, or to pay extra money for a clinic visit merely to get a sick note.
To address this dilemma, society, not doctors, should decide conditions for coping with short-term illness. Ideally, society would push workplaces to provide paid sick leave without the need for a sick note. Currently, no U.S. federal law mandates companies to provide paid sick leave.3 As of this year, only 13 states and Washington, DC, have enacted laws requiring paid sick leave.4 Studies have shown that paid sick leave is cost-effective because it reduces employee turnover and also reduces the risk of exposing the public to infectious diseases, especially in a pandemic like COVID-19.5,6 Patients with paid sick days have the autonomy to decide how to spend their health benefit and when a visit to the optometrist is necessary. Reducing the number of office visits scheduled only to request a sick note would better allocate optometrists’ resources to serving patients who are truly in need of care.
This is not to argue that the doctor’s note should be abolished altogether. On the contrary, optometrists can play an essential role in supporting informed decision-making by workplaces and schools. In place of sick notes, a better alternative may be “fit notes,” which England has been using since 2010.7 Such notes focus on what patients are capable of doing at work based on clinical examination and let the workplace decide what to do.
Moreover, optometrists need to educate patients through effective communication. According to the AOA’s Standards of Professional Conduct, “telling the truth is a necessary component of a trusting optometrist-patient relationship.”1 When facing unreasonable demands from patients, optometrists should educate patients about the difference between facts and feelings, as well as the limitation of optometry in decision-making for social dependencies. Patients need to understand that a reasonable request for a sick note is when optometrists need not create “sickness” for patients where there are just conflicting opinions.
It was not irrational for JM to be concerned about going back to work. His police work entailed extended outdoor activities (e.g., driving vehicles and directing traffic). Dry eye symptoms such as photophobia could increase the risk of accidents. In fact, per the Law Enforcement Officer Motor Vehicle Safety Report, motor vehicle-related incidents are a leading cause of line-of-duty deaths for law enforcement officers in the United States,8 most of which occurred during daylight, in clear weather, and at speeds lower than 50 mph.9 Nevertheless, JM’s dry eye had significantly improved and was deemed to be of minimal interference to his job and low risk for driving. Per the AOA Standards of Professional Conduct, “When optometrists provide expert testimony within a judicial or administrative action, the testimony should be balanced, fair, and truthful based on scientific and clinical knowledge.”1 Given the ethical obligations in this case, it would have been inappropriate to continue advocating for JM’s sick leave.
Because the sick leave policy at JM’s workplace cannot waive a sick note, we decided to take the fit-note approach and let his employer decide how to accommodate him on duty. Following the Standards of Professional Conduct that optometrists have the duty “to treat patients without prejudice,” and “to involve the patient in care and treatment decisions in a meaningful way, with due consideration of patient’s needs, desires, abilities and understanding,”1 we listened to JM’s concerns and educated and reassured him on his readiness to work. We involved JM in determining what he could do and could not do. For the interest of public safety, JM was encouraged to start office work with no vehicle use in the near term. He was also instructed to continue using artificial tears and warm compresses and scheduled for a follow-up visit. A fit note was provided to advise his workplace to excuse JM from operating vehicles and to allow him to perform indoor office tasks.
The requirement for a doctor’s note to take sick leave has many negative social implications. Because optometrists are ethically obligated to serve in patients’ best interests, positioning optometrists as objective authorities often leads to ethical dilemmas. Our society needs to legislate and expand paid sick leave without the need of a sick note, which affords patients the autonomy of seeking truly needed medical attention and improves their overall well-being. Optometrists ought to serve as advisors, not judges, to guide workplaces to make informed decisions on how to support employees during and after sickness.
- Standards of Professional Conduct [Internet]. St Louis, Mo: American Optometric Association; [cited 2021 July 12]. Available from: https://www.aoa.org/AOA/Documents/About%20the%20AOA/Ethics%20%26%20Values/Standards-of-Professional-Conduct_Adopted-June-2011.pdf.
- Code of Ethics [Internet]. St. Louis, Mo: American Optometric Association; [cited 2021 July 12]. Available from: https://www.aoa.org/about-the-aoa/ethics-and-values?sso=y.
- Sick Leave [Internet]. Washington, DC: U.S. Department of Labor; [cited 2021 Jan 28]. Available from: https://www.dol.gov/general/topic/workhours/sickleave.
- Paid Sick Leave. [Internet]. Washington, DC: National Conference of State Legislatures; c2021 [cited 2021 Jan 28]. Available from: https://www.ncsl.org/research/labor-and-employment/paid-sick-leave.aspx.
- Lovell V. Valuing Good Health: An Estimate of Costs and Savings for the Healthy Families Act, Publication #B248, April 2005 [Internet]. Washington, DC: Institute for Women’s Policy Research; [cited 2021 July 12]. Available from: https://iwpr.org/iwpr-general/valuing-good-health-an-estimate-of-costs-and-savings-for-the-healthy-families-act-2/.
- Maclean JC, Pichler S, Ziebarth NR. Mandated Sick Pay: Coverage, Utilization, and Welfare Effects, Working Paper 26832, March 2020 [Internet]. Cambridge, MA: National Bureau of Economic Research; c2021 [cited 2021 July 12]. Available from: https://www.nber.org/papers/w26832.
- Fit Note [Internet]. London, England: Department for Work and Pensions; [cited 2021 Jan 28]. Available from: https://www.gov.uk/government/collections/fit-note.
- Law Enforcement Officer Motor Vehicle Safety [Internet]. Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health; [cited 2021 Jan 28]. Available from: https://www.cdc.gov/niosh/topics/leo/default.html.
- Tiesman HM, Heick RJ. Law Enforcement Officer Motor Vehicle Safety: Findings from a Statewide Survey [Internet]. Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health; [cited 2021 Jan 28]. Available from: https://www.cdc.gov/niosh/docs/2015-101/pdfs/2015-101_v2-.pdf.