Inquirer Editorial: Refusing to hire smokers won't work

The University of Pennsylvania Health System is poised to join the growing ranks of employers that refuse to hire smokers. Hospitals, in fact, appear to be leading this misguided trend, which puts health-care providers in the vanguard of health-based discrimination.

Not only must hospitals treat patients regardless of how they are hurt or sickened, but payment for such indiscriminate treatment - whether by insurers, governments, or patients - makes them viable and often profitable. Hospitals don't refuse to treat anyone based on the cause of injury or sickness, and they certainly don't refuse compensation on that basis. Excluding a class of people from employment due to a health problem - and potentially preventing them from obtaining health insurance - is directly at odds with health-care practices and the principles behind them.

As detailed in The Inquirer last week, the New England Journal of Medicine recently published dueling commentaries on Penn's decision. In arguing for it, two smoking-cessation experts and the health system's chief executive, Ralph Muller, note correctly that smoking still takes an unacceptable toll in the United States and that quitting is very difficult. Therefore, they argue, it's time for sterner measures than the public smoking bans, cigarette taxes, and insurance surcharges already in place.

Muller et al propose a "ladder of interventions to reduce tobacco use," on which exclusion from the workplace is the sixth rung. It's worth noting that the only steps above that prescribe firing smokers already on the payroll and outlawing cigarettes.

Even if we assume that Penn and other employers are doing this for the good of society - and not just to lower their costs to provide employees with health benefits - they have crossed a boundary between discouraging smoking and demonizing smokers. Why is no one proposing such sanctions for other kinds of health liabilities, such as family history of heart disease? The stigma and misunderstanding surrounding addiction are part of the answer.

As Ezekiel Emanuel, a Penn vice provost and bioethicist, and two coauthors note in the commentary opposing Penn's pending policy, most of us should have the humility to recognize that addiction and other health problems could afflict us. "And," they add, "health-care organizations in particular should show compassion for their workers."

Addictions are by definition intractable, but we haven't accomplished much by removing addicts from society through imprisonment and other punishments. In fact, as the opposed authors point out, smoking rates are much higher among the unemployed and the poor. That doesn't bode well for the public-health results of policies that deny smokers a livelihood.