This document discusses restrictions and limitations that may be placed on seafarers' medical certificates due to health conditions. It outlines four categories of fitness: unfit for any duties, able to perform some but not all duties with restrictions, requiring increased surveillance, and able to perform all duties without restrictions. Restrictions aim to balance rehabilitation and safety by allowing seafarers to work within limitations of their conditions. Assessing fitness requires considering probabilities of impairment occurring and being able to mitigate its effects. Authorities must provide guidance and support to ensure consistent, evidence-based decisions are made regarding seafarers' medical restrictions.

1. Rehabilitation vs. Safety: restrictions and limitations
Tim Carter
Norwegian Centre for Maritime Medicine

2. Seafarer fitness assessment
Do they pose a risk to others, e.g. doing safety critical tasks, by transmission of infection, because of aberrant behaviour?
Can they perform their routine and emergency duties safely and effectively?
Are they themselves at excess risk of harm from a medical condition that could arise while at sea?
[Does their condition increase the probability of the ship operator having to pay care or repatriation costs?]

3. Variables
The time course of impairment: static (colour vision, amputation). Episodic (seizure, cardiac event). Progressive (muscular dystrophy). Fluctuating (rheumatoid arthritis).
Job related factors: lookout duties, lone working, food preparation.
Voyage related factors: distance from shore/care, duration of voyage, ports and their risks, climate.

4. Fit for all duties
Huge range – Vision requirements in cooks and in deck crew. Risks from food borne infections in deck crew and in cooks. Tropics and their ports to polar regions. Voyages of several months.
But most crew do defined duties on particular types of ship following regular voyage patterns.
Assessment based on fitness for a particular job is good practice in onshore Occ. Health. Anti- discrimination requirements in employment law in developed countries demand it.

5. Application to maritime sector
Often seafarer fitness assessed without knowledge of duties/ship/voyage pattern.
Seafarers want flexibility when choosing a job.
Motives of those specifying fitness requirements vary: maritime authorities just concerned with safety, maritime authorities concerned with seafarer health risks as well, employers and P&I Clubs additionally concerned with costs, crewing agents wanting to offer only fully fit seafarers.
Law on discrimination weak in crewing countries

6. Solutions
Differ for statutory medicals worldwide where human rights must be respected and for commercial operators in crewing countries where economic aspects can dominate and there is no appeal against rejection.
Statutory: ILO Maritime Labour Convention 2006; IMO STCW Convention, Manila Amendments.
-Certificate of fitness, may specify limitations or restrictions on fitness.
-Job specific standards for vision
-Right of appeal
-Capability based for stable impairments

7. Framework for restrictions/limitations
ILO/IMO Guidelines on the medical examinations of seafarers. Para 56
(A)Incompatible with the reliable performance of routine and emergency duties safely or effectively: (i) temporary (<2 years) – unfit, no certificate (ii) permanent (>2 years)- unfit, no certificate
(B) Able to perform some but not all routine and emergency duties or to work in some but not all waters: certificate with relevant restrictions specified.
(C)Increased surveillance needed: limited duration (<2 year) certificate
(D)Able to perform all duties worldwide within designated department: unrestricted, 2 year certificate.
Based on approach used in UK for many years. ADs have to decide on category of fitness. This is based on summary information in condition specific standards, supplemented by additional guidance on complex conditions.

8. Restrictions and safety
Every prognostic decision involves probabilities.
1- of impairment
2 – of impairment when it matters
3 – of inability to mitigate effects of impairment
Colour vision impaired. What level matters for lookout duties? Is it relevant to work as an engineer? What are the effects of making an error?
Cardiac arrhythmia. How often present? Is consciousness/performance impaired? What is likelihood of of incident from this during bridge watchkeeping? Is a second person there to take over?
BUT visual errors and impaired performance from inattention occur with those who do not have prior risk factors. So how much is risk of serious incident reduced by fitness assessment?

9. Restrictions and rehabilitation
Minor use – most relate to continuing conditions.
Safety should not be compromised e.g. how soon to return to safety critical duties after a cardiac event or seizure? Baselines – 60 yr. old seafarer c 1% p.a. risk of sudden loss or consciousness without detectable predispositions. 3 months post cardiac event if risk factors absent, based on consensus view of evidence.
Any trade off with safety is not about rehabilitation but about keeping seafarers at work. Most of risk relates to the risks to them from being distant from medical care if an existing condition recurs (renal stones) – limit to coastal duties or if treatment needs adjustment (type 2 diabetes). – time limited certificate.

10. Implications for ADs and Maritime Authorities
How requirements are specified. Principles of risk assessment and how to find evidence or detail on what to do for particular conditions and situations.
Availability of help for decisions on difficult cases, with lessons learnt and used to improve advice to ADs
More AD training needed if no help and are decisions based on principles than if helpline and prescriptive guidance.
QA of AD decision taking needed to ensure performance and consistency.
Support from referee system with its own QA.