Jacob M. Appel, M.D., J.D.

The vast majority of physicians will encounter a patient who is unfit to drive an automobile as a result of cognitive impairments, untreated epilepsy, chronic intoxication or other underlying medical conditions.  Whether providers are permitted to break confidentiality to report such patients to the authorities—and whether there are certain circumstances in which they must do so—remains a difficult legal and ethical quandary.

 In the United States, various jurisdiction assign widely different rights and responsibilities to physicians under these circumstances:  Six states require caregivers to report impaired drivers in some situations, twenty-four states permit such disclosure at the physician’s discretion, and twenty states have no statutory law at all on the subject.   Leading medical societies, including the American Medical Association, American Academy of Neurology and the Medical Society of New York have issued conflicting guidelines regarding such reporting.  Federal policy allows physicians to breach the confidentiality rules of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) “to avert a serious threat to health or safety,” but does not spell out how this applies to impaired driving.  In short, conscientious physicians face much uncertainty as to their obligations.

The ethical and practical implications of breaching confidentiality to report impaired driving are complex.   Physicians have both a duty to serve their patients and to uphold the public welfare.  Driving may be an essential aspect of a patient’s independence or wellbeing, while losing a driver’s license can prove a significant psychological blow to the ego.  Moreover, the essence of the physician-patient relationship is based upon trust; violating that trust by reporting a patient’s impairment to the state may damage the relationship permanently.  Yet it is not entirely clear that physician reporting actually makes the public roads any safer in the long run.  If patients come to believe that they cannot trust their physicians, some will attempt to conceal impairments such as seizures—and rather than giving up driving, they will give up medical care.  One high profile case had precisely that effect:  When Keith Emerich’s physician reported to Pennsylvania authorities that he feared his patient was driving while intoxicated, it provoked a national backlash that led many patients to second guess their faith in the confidentiality of their medical encounters.

The dilemma of impaired driving is not likely to disappear any time soon.  As life expectancies increase, so will the number of elderly drivers whose physical and cognitive abilities render them unsafe behind the wheel.   How best to handle this challenge—in a manner that serves the welfare of vulnerable patients and the public—is going to require the concerted and committed efforts of both the international medical community and national governments.  At a minimum, the crisis calls for physicians to educate themselves on applicable laws in their own community, as well as regarding resources available to patients who are no longer able to drive.

References:

(1) Appel, JM.  Must physicians report impaired driving? Rethinking a duty on a collision course with itself.  Journal of Clinical Ethics. Summer 2009;20(2):136-40.

(2) Berger JT. Rosner F. Kark P. Bennett AJ. Reporting by physicians of impaired drivers and potentially impaired drivers. The Committee on Bioethical Issues of the Medical Society of the State of New York. Journal of General Internal Medicine. 15(9):667-72, Sept. 2000.

(3) Gupta, Malkeet.  Mandatory Reporting Laws and the Emergency Physician.  Annals of Emergency Medicine, 2007 40: 369-376.

(4) Krauss GL. Ampaw L. Krumholz A. Individual State Driving Restrictions For People With Epilepsy In The US. Neurology. 57(10):1780-5, Nov 27 2001.