Fitness to work in all modes of transport, where this may put members of the public or other workers at risk, has long been an area of public concern. Because inadequate performance may endanger fellow workers or the public and put expensive assets at risk, frameworks for statutory regulation have been developed. This chapter uses fitness to drive, the area of widest interest, as an example, but each mode of transport has its own pattern of performance requirements and hence fitness standards, although they have much in common. Separate appendices cover fitness to work in the rail industry, as a seafarer, and in aviation. The risks to the safety of others posed by performance deficits or incapacitation has meant that decisions on fitness are frequently taken not for the benefit of the person examined but to safeguard those at risk as a consequence of their actions. Hence hard decisions often have to be taken and for this reason standards for medical aspects of fitness are usually formal and often published. They are usually applied by physicians acting on behalf of regulatory authorities and have associated review or appeal mechanisms available to those who have been failed or restricted. Standards are necessarily based on the balance between public risk and potential loss of employment, with the former predominating. The evidence base for current standards is of variable quality and this is often a cause of contention. Patient groups and equal opportunities organizations may find it difficult to accept the concept of standards based on epidemiological evidence of risk. They may cite equality legislation to encourage applicants to demand individual assessment of risk and job adaptations to allow employment, often in situations where this is impossible. In addition to long-term health problems that are handled by reference to such formal standards, transport workers may also have short-term decrements in performance from injury, minor illness, or medication. In some areas, e.g. aviation, even short-term decreases in medical fitness are subject to national or international regulation.
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