Subjectivity in the certification of sick leave
An ontologically objective notion of disease lies at the root of the national insurance legislation as well as of the diagnostic classification itself. In most cases, however, the doctor’s diagnosis will be based on subjective symptoms, and not on any objective findings (8). In spite of the apparently rigid regulations, practices show that many people are granted long-term sick leave or disability on the basis of diagnoses of symptoms with no objective findings (3). How should we understand this?
The circular from the legal sources provides an opening for the use of medical wisdom and clinical discretionary judgement (6), but the guidelines strictly require that in this exercise of discretion the doctor should not be biased by personal assessments and points of view (2). Solli et al. claim that the Norwegian tradition of allowing an unencumbered and unregulated use of medical discretion could be regarded as a form of epistemological subjectivity, and call for a more qualified and less arbitrary exercise of discretionary judgement based on epistemological objectivity (10). However, it is in the nature of discretionary judgement always to include elements of arbitrariness and variation, and decision-making situations with a certain measure of indeterminateness are implicit in professional medical practice (11).
Solli’s operational definitions of various concepts of objectivity and subjectivity can serve as a useful model for describing gradual transitions from ontologically objective to ontologically subjective assessments in the doctors’ exercise of discretionary judgement. As a main rule, medical discretion should be based on the medical knowledge and skills of the individual professional, although any assessments of disease and functional ability may include a non-medical element, in which the personal values and moral convictions of the doctor may be involved (5). This constitutes a significant normative problem, referred to as «the burdens of discretion» (11). Three elements in particular have a bearing on the burdens of discretion. These are the casuistic features of discretionary judgement, indeterminateness as a variation in the environment and an ever-present element of first-person experience (11). This means that the decisions made by the person exercising discretionary judgement will be influenced by his/her personal experience from similar cases, local cultural conditions and his/her personal life experiences. A study of doctors’ assessments of sick leave for people suffering from unspecific health complaints confirms the wide variance in the assessments made in this context (12). Many doctors are uncomfortable with issuing a certification of sick leave when the clinical situation is incongruent with the legislative framework, and the assessments appear to be coloured by the personal experiences, attitudes and personalities of the doctors (12).
Because of the legal requirement for a medical diagnosis on social insurance certifications, we may see an unfortunate medicalization of life problems and social problems. We see that in practice, many of those who are granted sick leave are provided with an arbitrary medical label based on relatively minor health complaints, while the real reason for their reduced functional capacity is related to life problems. This lack of correspondence between the legal framework and actual practice means that the «map» does not always correspond with the «terrain». It may appear that in the practical application of sick leave, the terrain must be adapted to the map, rather than the other way round.