The different roles of flag state authorities, insurers, crewing agencies, seafarers and ship-owners influence the way they look upon risk in the context of medical selection. While all share common objectives like safety for ship and crew, they vary in the emphasis they put on other aspects, like rights to work, safety of operation, loss prevention, flag reputation etc. The drivers for development of criteria development differ. Hence, the criteria also differ.

The objectives of the health assessment define the mind-set of the medical examination, and the approach of the medical examiner. The medical examiner could interpret a criterion differently under different mind-sets and objectives.

Regardless of type of PEME programme, the need to use a heuristic approach and the limits of evidence-based criteria are striking. We have to face this challenge in the future.