Subjectivity in certification of sick leave



    People who approach the health services to request sick leave often suffer from unspecific health complaints that have complex causes. The National Insurance Service’s regulations clearly stipulate that a reduced ability to work should be caused by disease or injury. Medical assessments related to social insurance claims take place at the confluence of the patient’s subjective perceptions and the doctor’s objective medical assessments. The purpose of this chronicle is to highlight an obvious incongruity between the legal basis and the practices for granting sick leave, in which the doctor’s subjectivity is rarely discussed.

    Drawing by Stein Løken
    Drawing by Stein Løken

    Guidelines are required to determine who will be entitled to wage compensation when individuals are unable to carry out their work. A reduced ability to work may be influenced by the health of the individual in question, but is also related to the interplay with his/her environment and the demands the employee is facing at work. However, the rules that regulate sick leave and other national insurance benefits are based on the requirement that the reduced functional ability should be caused by disease or injury (1). The doctor is responsible for certifying that the medical requirements have been complied with.

    In the role of medical expert, the doctor should seek to maintain his/her objectivity and impartiality to the greatest possible extent (2). This ideal of objectivity is based on a traditional notion of disease derived from the natural sciences, in which disease is a measurable phenomenon. Even though there is widespread agreement that reduced functional capacity is based on a complex set of causal factors, national insurance legislation appears to have an exaggerated faith in the capability of the health services to determine whether the reduction in functional ability is caused by an objective disease. This kind of natural-science approach is inadequate as an explanatory model for unspecific health complaints with complex causes. This represents a problem, since unspecific health complaints with no observable pathologies or objective findings tend to be characteristic of those on long-term sick leave (3). In the practical determination of whether or not sick leave should be granted, the patient’s perceptions represent the subjective and the doctor’s assessments the objective element. The doctor must exercise professional discretionary judgement, which may imply various forms of subjective assessment (4, 5).

    The purpose of this chronicle is to discuss how concepts of objectivity and subjectivity are taken into account when sick leave is considered, and how these relate to professional discretionary judgement. The discussion will be based on the regulations pertaining to sickness benefit in Section 8 of The National Insurance Act (1), but the main points in the discussion are equally applicable to other forms of health-related benefits. I also wish to elucidate the practices related to sick leave seen in relation to diagnostic classification systems and how the notion of disease is understood.

    Objectivity and subjectivity

    Objectivity and subjectivity

    Solli has operationalized various concepts of objectivity and subjectivity that are used in national insurance medicine (4) (tab. 1). Objectivity and subjectivity are studied ontologically (the theory of what exists) and epistemologically (knowledge theory) (4). Four concepts that emerge from the table can be exemplified medically as follows: Ontological objectivity is based on a traditional approach derived from the natural sciences. According to this approach, diseases leave discernible traces in the sick person’s body. Ontological subjectivity describes matters that exist only in the human consciousness, such as the perception of pain. The requirement that a health complaint must comply with certain criteria to satisfy a specific diagnosis is an example of an application of epistemological objectivity. When the doctor undertakes assessments of a non-medical nature in his/her decisions related to sick leave, these can be described as epistemologically subjective.

    Table 1

    Concepts of objectivity and subjectivity in national insurance medicine (4)




    • things

    • independent of human consciousness or knowledge

    • factualness

    • impartiality

    • neutrality

    • precision

    • intersubjectivity

    • generality


    • dependent on consciousness

    • prejudice

    • bias

    • imprecision

    • arbitrariness



    There is often a poor correspondence between the legal framework for sick leave defined by the National Insurance Service and actual practice in the health services. A number of unspecific health complaints cannot be explained with the aid of an ontological concept of objectivity. Exercise of discretionary judgement is a key element in the granting of sick leave, but this fact is rarely discussed. There is a need for a greater degree of reflection and discussion about the subjective assessments made by doctors in matters pertaining to sick leave, including how the legal framework functions, so that the map corresponds better with the terrain.

    I wish to thank Hans Magnus Solli for his review and valuable comments provided when this manuscript was in the final stages of preparation.


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